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FOR OFFICE USE: FOR OFFICE USE: lr APPLICATION FOR SANITATION PERMIT ------------------ � ------- ------ 77— Shy: (Complete in Triplicate) Permit No__ _______________ - - A Date Issued_7.— c' .7 7 . -------- ------------- --------------- - ---- ---------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San 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/ IONI�s� /+/r -------..-.CENSUS TRACT----- - Owner's Name aa-? = = ---------- - Address fir" ' -�--.---- City_ . - * r+ti p Cit Y i Contractor's Name----- l G`"'`� ----------- -License # z Z Phone - - r . Installation 7will serve: a Residence ❑i` Apartment House ❑ Comm tial ❑ 'Trailer Court Elt i• Motel El Other- -L�- -y- ------ i Number of livingunits:___-_. --- _Number of.bedrooms 1 �� Garbage Grinder =._Lot.Size--- --------- ------------------------ Water Supply: Public System and name____ ______________..... _ --_:_"--------- -------------------------------------------------------- .------- --------Private I Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam❑ Clay Lo 'm 3 Hardpan ❑ Adobe ❑ Fill Material...____...._If yes, type_-.#.-_-_- (Plot plan, showing size of lot, location of,system in relation to wells, buildings„etc. must be placed on reverse side.) NEW INSTALLATION: (No septic. p p ge pit permitted 'if public sewer,is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC-TANK ”[ �Sie= Depth .f--- ----y E Capacity.-I p �,-TYpe- - '-- Materials i I - � ,. • `~- ' -:: °: Compartments = ------------ Distance to nearest: Well _ - �U F�. ui� = Foundation �' � Prop. _Line a- Fou i LEACHING LINE: No.cof-L-in s" `; .-' Length.of each line-� �...}` Total tel Length J —D Box.... J T" a Filter Material.... S -.Depth Filter Material..-. __ _____ ___ __ _____' Distance to nearest: Well- ...Foundation--------I.U. -------Property Line __~ SEEPAGE PIT [ Depth 2-' iameter_ -----------:-r`--Number......___.. --------_'___... ; Rock Filled Yes �No WaterTable Depth �' = Rock Size'-1_! 31 -- -- --------- --------- E Distance to nearest: Weli_-.i----:- - -Q--1-- t ":`------->-,Foundation--:----�-�- - Prop. tine-.--- - -- ' 's ) REPAIR/ADDITION (Preva Sanitation Permit#----------------------=-----------------------------Date------- -_.--_ f } - ----------------- ------------ Septic Tank {Specify Requirements)--- - __--_.-_ ) s ------------ - - ----------- r -------------- --------------------------- Disposal Field (Specify Requirements)-.,.-.............. : _ [ _ - --------- --------------- --------------------------------------- - __ _____ _____________ ---------------------=- - ---------- I (Draw existing and required addition on reverse side) I hereby certify that.( 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 the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: . p , "I certify that in the performance of'the work for which this permit is issued; I shall not employ tiny'person in such manner as to become subject to Workman's. Compensation laws of California." 4 r Signed-- -- --------- -- -- - --- --=---- ---Owner E I ByB ------------------- ------------ = Z Title------------------------------- ------------------- , I I } (If other than owner) R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- _ - - -- DATE. ------------------------- DIVISIONj OF LAND NUMBER----- -------- ------------ - DATE : :- -= :... ADDITIONAL COMMENTS--------------------------------------- ------------ - ----------- -------------- --------- - ----------•--------------------- --------------------------- : -------- ------------ ----- , -- --------------------------------------------------------- ----------------------------------- ----- =---------------------------------...------ - ----- - - ------- Final Inspection by.,--.---:--- --------------- = `= ----------------------------- - ".' "_-Date. - - - - ------------------------=------ eH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT a=as 21677 Rev. 7176 3M