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FOR OFFICE USE: FOR OFFICE USE:- f, APPLICATION.FOR SANITATION PERMIT ------------ 77- (Complete in Triplicate) Permit o_______________________ /1—�-7 --- --- - - Date Issued- -------------- ------------- ----------------------- ------- This Permit Expires 1 Year From Date Issued Application is hereby made to the'Son Joaquin Local Health District for a permit to construct and,install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB � ADDRESS/LOCATION_----/ _ ' i '---CENSUS ---------- - --- - -- ------------------------------- -'i -CENSUSTRA T ------------...- w � --- --- ------: _ IPhone - -'-O -- - Address-----=------------- ---fX—flefL�-• - City--- -- ----- -- -- --- ----- ----ZiP--- ---- ----------- 1 Contractor's Name :. Y icense #. . '- ,v_--Phone--------------- -. r i �U � � Installation,will serve: Residence ❑ ? Apartment House E] Commercial iTrailer Court ❑ s f-Motel O—Other------------------------------- -------------- Number ---- -----Number of-living units-----------------Number.of bedrooms------------Garbage Grinder-j' -Lot Size---------------------------_-------------- -______ Water Supply: Public System and:name---- =--- 1 - -------------'------------------------------------- F------ - ------Private t 0 Character of soil to a depth of 3 feet./ Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ - F Hardpan Adobe ❑ Fill Material—_----_---If yes, type_.__-_______-__:--___:-.-._-. (Plot plan, showing size of lot, location of system In relation to`Wellsdl/; buildings etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank-or seepage pit permitted if public sewer is-available within 200 feet,) ; PACKAGE TREATMENT [ ]- .'SEPTIC TANK"`[)] Size------------------- - `- -----------------------------Liquid Depth---- ---------------------- Capacity--- -------------- --- CapacitY--- :c TYpe-_.==�.:_..�_..___.-__:Material-------= >_. :' No, Compartments—----- ------------------------ Distance to nearest: Well. ._ ' _ _- ---___ Foundation—-] --:-_'----------------Prop. Line-------------------------- F LEACHING LINE [ ] No. of Lines__-------------------- Rof.each'line.___-_______.- Total .Length _,-- _--.- -_-_ ----_-.-__-_ D' Box-- ----------_Type Filter Material_---------------------Depth Filter Material--- - -- ------I------------------------------ __---_---. Distance to nearest: Well__'___,?-------------'---._Foundatian--- ---- --------------------Property Line__.____._-___-_-___-__-_ � .. - SEEPAGE PIT [ ] - Depth.- D meter------------------LN' umber-`. - ______.__ ------------ Rock Filled Yes ❑ No Ti Water Table'-I]epth._�T.__ ------------------------,__ . :`Rock Size----------- ------- 'Distance -_'Distance to nearest: Wx ; _ ----:. _ . i- Prop. Line_4— REPAIR/AD' DITION ;REPAIR/ADDITION {Prey. Sanitation Permit#_ "-______------------------- =- :_- _---Date------ ?'J Y`` --_._____-_____-- ____) Septic Tank (Specify Requirements)-----------------------._ � - ---- - -----�--�-f- -------- Disposal. Field(Specify,Requirements)----- - -fit" - - ------ - --------------------------------------- ----------------------- ---- ----- -------------------------- -r ------------ - --------------- --- ---- ----------------------- ------ ----------------=----- ---------------------------------------------------------------------------------------- -------------- (Draw existing and required addition on reverse side[ + hereby certify that I have prepared this-application and that:the 'work- will be•done-in••accordance with San Joaquin County Ordinances, State-laws,.._and_Rules.;.-and_Regulations.of Tthe^San_Joaquin Local Health District. Home owner or licensed agents signature certifies the following:,"I.certify that in the performance"of;the work:for`which%this permit is issued, I shall not employ any person in such manner�as to become subject to.Workman's Compensation'laws of California. I Signed _ nar + �. BY-=--------------------------------- _ Title - _ ' (If'other than owner} 'F9R DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY---- ..-------- 97 = . ----DATE 9-" ..-~--- ----------- DIVISION OF LAND NUMBER ---------- --- - = - ------------------ ---DATE-- ----------- ---- ------- ---=---s- - ADDITIONAL COMMENTS------------------------------- --------------------------- ------ ------------------------- = ------------r------------- -- ----- ------------------------------------------------------------- ---- -------- --- ---- f ; -------------- _______________________________________________ - _ _ --- - -_------_-_--_.--__.__--__-_____-_---------.---___-.---.._-----___---._______._____ _____._________ __- Final Inspection by------------ ----= - _ - Date r - ] EH 13 24 SA J AQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76'W