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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit ------------------------ Date Issued__�=2 3-77 _____________________________ ------------------------ 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: 11 JOB ADDRESS/LOCATION--.-----_ -�-t �_/--- -- s--------------- -- --- CC. -.-----_-------------------CENSUS TRACT-------- Owner's Name-------------- -lY F - V Phone -------------- ------------------------------------- Address--------------------- - -� I 1 - -City ,el. e.1 Zi Contractor's Name---------- S -----._-------------License # --1_T.3.__Phone.--` 6`g44 --- Installation will serve: ResidenceApartment House ❑ Commercial F] Trailer Court El ttel ❑ Other----------------------------------------------- Number of livin units:_.-___ ____Number of bedrooms_.__-3---Garbage Grinder------------Lot Size------ / I Water Supply: Public System and name-------------------------------------------------------- Privatee 4 � ti Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam IF, Clay Loam 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 tank or seepage pit permitted if ublic sewer is available wifhin 260eet,) ` iy PACKAGE TREATMENT [ ] SEPTIC TANK 'ze---------------X__ - ____Liquid-Depth- __ - -------- - - - ----- Capacity !- - - -- -Type-- - -------Material---- No. Comportments- �'�� -f- Distance to nearest: Well.---_-- ----r-__--_-_.__-.__Foundation------ Line .__ ___ .._ ------------ LEACHING LINE No. of Lines------3_----------------Length f e ch line.----- _0__Of___________Total Length.______ ----_________ D' Box_ Type Filter Material-- Depth Filter Material _-__ t Distance to nearest: Well_____ Q '---- ___Foundation_____�fl "t"_ Property Line_ .. "f`___._--_ . SEEPAGE PIT [ ] Depth__ _ ________-Diameter______ __________Number_.-_____ _.____------------------ RIE'F111 `Y,es No Water Table;Depth---------------------------------------------------------Rock Size_ -- ------ Distance to nearest: Well ----- --- --- -.Foundation----------------- - --_Prep. Llrlec ,_ t REPAIR/ADDITION (Prev. Sanitation Permit#.---------------------------------- ------x-`tea--------------------------- ------------------ Septic ----------------Septic Tank (Specify Requirements)---------------------- --------------------------------------------------------------------------------- -------- ---- -- Disposal Field(Specify 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed-------------------- ------------- Owner By--------- ----- t------- - - Title-----------c"' If o e than owner) .... —7-MR,DEPARTMENT USE ONLY`- APPLICATION ACCEPTED BY_________ _______ __ __ - -------- --------------------------DATE DIVISION OF LAND NUMBER------------------4Z---------------------------- __DATE________ ADDITIONALCOMMENTS------ -------------- ------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------- ----- --- - ------------------•-------------------------- ------------------------------------------------------------------------------- - ---- -- --- - - ---- --------------- -----Final Inspection by:------------------ - ---Date---- -- ----©- --__,7_ -------------------------------------------- �SAN EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. n