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FOR OFFICE USE: `� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------ Permit No.--7�" �>/ (Complete in Triplicate) -------------------------------------------------------- / Date Issued -/�-__ -._.._-_7 1 .•__-_____-_ ---_._______________.__-___.__ 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: �f JOB ADDRESS/LOCATION >------ ------11 �� _T ----CENSUS TRACT------------------------------- Owner's Name --Me-611----- ------- --1 ` ----------- ------------------------------------------------------------Phone-------------------------------------- 66�� Address----Z! 5 °�--- ----- �1 v4-' F't'C�^ --/� L`4 ---------------------City K'lC ---------------Zip_ 33 ;------ Contractor's Name------AI _41---I_ _ �----------------------- --------------License Installation will serve: Residence J�gf Apartment Houses❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------------------------------------- 7 Number of living units:-----I of bedrooms__: -----Garbage Grinder-------.----Lot Size_._ --, I______ ______-___ __ w-------.--------- Water Supply: Public System and name------------------ .. `j__ _Private Character of soil to a depth of 3 feet: Sand Ef Silt❑ Clay ❑ Peat ❑ Sandy Loam Ig Clay Loam ❑ Hardpan ❑ Adobe E) Fill M6terial- .-.._If yes, type-------------------------------- (Plot _____________--__ _(Plot plan, showing size of lot, location of systems -relation to wells, buildings, etc. must be-,ben revws2 side.) NEW,INSTALLATION: ]i`lo'septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1 _ PACKAGE TREATMENT [ ] SEPTIC AN K.- ] `STI€-' x-41— R`--.J__ _ ____ _______Liquid Depth-_J� _ �_________�1 Ca0acitylf e,"Z TYPe e�'- - ---- tarial--------- ------------.--No. Compartments-------- - - Y t � ( c... t , 37C1. t. � Distance to nearest: Well___--_ _-___________________________Foundation.__ ? -------------- Line_ - _C1.---_--____-_. LEACHING LINE [ ] No. of Lines__-,_____________ _ -Total Len ----.Length of each line f �- gth � c'� 1 /f 'D' Box-4. Filter Materiat/llXV, Depth Filter Material..___, ____._______ ___ _____________._________ f f 'S Distance to nearest: Well-,�t _ ____._____Foundation G -------------Property Line__;__ „ ________________ SEEPAGE PIT ( ] Depth--- ----------.-_Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑� WaterTable Depth---------------------------------------------------------Rock Size-----------------------------------'------------ Distance to nearest: Well_______________________________________Foundation--------------------------Prop. L'ine_______________________- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------.________-___________-Date__________-_______________________________); SepticTank (Specify IeeElGirderients)----------- -------------------------------------------------------------------- ------- ------------- ------------------------------ ------ tDisposal Field(Sp&fy Requirements),----- -- -------- ----- ---------------------------------------------------------------------------------------------------------------------- ----- ----- ---------------------------------- (Draw existing and required addition on reverse side) I 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 the 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, 1 shall not employ any person in such manner as to become su ect t Wo an's Compensation laws of California." Signed--- -_ - `- ---- --- - ---------------- -------__------ -------------Owner By------------------------------- ----------------------------------------------------------------------.Title---------------------------- -------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------A7 - ------------- ------------------------------------------------------------ -----DATE.-- / ----�� --✓ -7-77 ------- --- DIVISION OF LAND NUMBER.--------- --- - - --- ----------------------------------------------------------------------- ------DATE-------- --------------------------- - - - - -- ADDITIONALCOMMENTS------------------ ----------------------------------------------------- ----------------___1------ -------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- ----- -- ----- -- --- ---- ---- ------------------------ -- ---- - --- •- ----- -- - -- --------------- - -- - --- --------- ---------- - ----------- - - ------ ------ ---------------- -- Final Inspection by:. Date'. ; �� 7 EH 13 24 SAN-JOAQUIN LOCAL HEALTH DISTRICT Fess 21677 REV.