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FOR OFFICE USE: -------------------------------------------- APPLICATION FOR R SANITATION PERMIT FOR OFFICE USE: ------------------------------------------ (Complete in Triplicate) S/ Permit ------ This Permit Expires 1 Year From Date Issued Date Issued_-?��=a�"77 ----------- Application is hereby made to the SanJoaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54r and existing Rules and Re ulatio JOB ADDRESS/LOCATION__-- _ g ns. Owner's Name--- ---------!4-g �� Z� --------------_---CENSUS TRACT---._ -- -- Address ------------------------------------------------------------ -------------Phone--O:?----------------------- Contractor's Name Name---- �U� -------------------------CitY �---- - Installation will serve: License. Residence � ��--�'hone_��_�_�� [�' Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other__ Number of living units:__ ----------Number of bedrooms ----_-__Garbage Grinder Water Size_____"�� Water Supply: Public System and name_____-___-___ of soil to a de th of 3 feet: ------- ----------- - - ----- - - p - - - ---------- Character - Sand - ------ --------- - _Private• ❑ Silt❑ Cla - --------------------<- Hardpan ❑ Adobe y ❑ Peat[] Sandy Loam Clay Loam ❑ Fill Material_ -----If Yes, type------------ ❑ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be laced NEW INSTALLATION: (No septic tank or seepage P on reverse side.) PACKAGE TREATMENT pit permitted if public sewer is available within 200 feet,) [ l SEPTIC TANK [ ] Size-------- ------------------------------ Capacity - - T e •AE'f�9,S'J' - Liquid Depth--- ' Yp Material ------------------------ - No. Compartments--_--�---------- �/ Distance to nearest: Well--- LEACHING LINE Foundation Prop. Lilnep._ _- - J No. ofLines_ -------------------- Length of e�ach I1 > ___ _ Total Length. 'D' Box___ ------Type Filter Material-/4 t-tX .Depth Filter Material_- 4 Distance to nearest: Well__,��-y_ _------ ,n _Foundation__ 3 �-/ -------------"'V SEEP PIT [ ] Depth---,._,-, Diameter --------- Property Line- SEEPAGE =----Number - - ----- Water Tablew Depth._ Rock Filled Yes❑ No ----------------------------Rock Size ------------------------------------ REPAIR/ADDITION - - "i. Distance to nearest: Well - -Foundation---------- Prop. Line_ REPAIR/ADDITION (Prev. Sanitation Permit-#--------------_-_ Septic Tank (Specify Requirements)---------- , Date ------------ ------------------- ------------------------------ Disposal Field(Specify Requirements).____-_- -- ----- -- - ------- -- --------------------------- __ -------- ------ - ------ ----------------- (Draw existing and required-addition on reverse side) hereby certify that 1 have r --------------------------------------- --------------- hat li@ work )rdinances, State Laws, and Rules andaRegulatlons not tthe tSan Joaquin 4-done in accordance with San Joaquin County ignature certifies the following: q caLleijth District. Home owner or licensed agents I certify that in the performance of the work for which this become subfect to W rn �t.esmit s ssued, i shall not employ an s Com sation laws of California. P y Y person in such manner as 'gned_---------�. , ------------ ---- ------------------------------C>wvner ----------- ------------------------------------Titf'e------- -- ------------ FPR other than owner) R DEPARTMENT USE ONLY 'PLICATION ACCEPTED BY______ VISION OF LAND NUMBER-_- --_--- ------------------------------------------------- DATE - .--- ---- ...... )DITICdNAL COMMENTS____--- ------ ------ DATE A ------------------------- --------------------� ----- -- alInspection b -------- ------------------------------------- -------------------------------------------- -------------------------------------------- 3 24 ----------------------•-------- --- ---------------------------------------------Date--'-------r - �----- -------- - ----- - - SAN JOAQUIN LOCAL HEALTH DISTRICT / � -- F&5 21677 REV. 7{ 3