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FOR OFFICE US FOR OFFICE USE: �� APPLICATION FOR SANITATION PERMIT ----------- - - ------------- ---------- - - (Complete in Triplicate) Permit No.__77-/01_ __. --------------------------------------------------------- Date Issued____________________ -.__________________.______._______.____._.__.__.-_ N 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/LOCAT N__,�17_37...... - _ 9_ "_CENSUS TRACT------------------------------- Owner's Name--------- --- --- ---------------¢--,--C-- -------U-- ----Phone---? 2 Address------------------ _ ---------- ---------------------------City- ------------------Zip-_----.'---Q----�---�-- ------------- ---------------Contractor's Name------- --- ---- ---------------------License # ,5 '"---- -3-----Phone_Y44__?667-------- Installation will serve: Residence❑ Apartment Hous .❑ am rcial E] Trailer Court EJ Motel E] Other...__--- ,, ._._-- cgix " f�Cld `rt Number of living units:-------------.__Number of bedrooms------------Garbage Grinder------------Lot Size------------------ ______________.____________.___ Water Supply: Public System and name----------.-------- ---------------------------------------------------------------------------------=;,---------- -----------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe V Fill Material--.--------- 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 public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size_____ i /I -L - -- --------------------------------Liquid Depth.-------- ---------------- Capacity-_ --------------Capacity__ O_______Type-- __Material__ �� _1 /LGm --------Z------------------ . ...... . Cp Distance to nearest: Well----- -------Foundation_3�_________________Prop. LineZS __-�'__________-_`' LEACHING LINE YY No. of Lines--------�-------------Length of each line._ --------------------------Total Length----/_?0-----------------____---_ 'D' Box__________Type Filter Material__ ______Depth Filter Material-----------`, _._______________________________________- Distance to nearest: Well-----1 �� '---Foundation s____, ---�____--Property Line___________________________________ � cf SEEPAGE PIT r,] Depth___, S____Diameter___,�;_-.______Number___________y__________. / Rock Filled Yes 9 No xl� Water Table Depth--------------------------------------------------------.Rock Size __ ._� _ _ .�_._____ - Distance to nearest: Well---------- -- --------------Foundation _ Or 1F-_--------Prop. Line------------------------- REPAIR/ADDITION _- _-- -._____ —REPAIR/ADDITION (Prev. Sanitation Permit#_____________-` -::=_'_._----_______________Date___________________________,______________.___I SepticTank (Specify Requirements)------------------------------------------------------------------------------- ------------------------------------------------------------- --------- Disposal Field(Specify Requirements)---------------------- ----------------------- ---------------------------------------------------------------------------------------------------- --------------------------I--------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------------- ---- ------------------------------------ (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---- -- - w --- ----------------------------------Owner - kc__ By------ ------------------------ ----------Title------------ ------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------------------------------------------------------------------------DATE.----- ------- DIVISION OF LAND NUMBER_------- --------------------------- ------- ----------------s------------------------------------DATE----------------- -------------------------- ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ---------- - ------ .......i- - --- --------- 7 C�-.e�.�ict +� -_ , -- ---.119 - -- -------'----�`-�SiG'�'- c'�'`--, 2 t_ ------------------- ---------------------------------- i - ''��- - ----- � Final Inspection by:------------------------------------ ----------------------------------------------------------------------------------6ate-------------------------------------- �.�s --------------- `�� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M