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FOR OFFICE USE: FOR OFFICE USE: -� ""'APPLICATION FOR SANITATION PERMIT --------------------------------- =. •- s Permit No_--_-��-. y7 (Complete in Triplicate) ---------------------------------------- ------ 77 .!"` "-- .�Date Issued.... `_�'-------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/LOCA � f / � 0 i - ------------�- -------- ----- - _ ----- ----------------------- ---"CENSUS TRACT-.---- --- ----------- Owner's Name <--sf __ Address - ------ -- --------------------------City-- v� "---Zip- Contractor's Name--:-------- ____.. --- ---� ��'�-.��:�__W,-Vt_ License -- ---Phone-----��D`��$��- Installation will serve: Residences Apartment Housef-] Commercial ❑ Trailer Court ❑ _ ' l ;--M#tel.❑ Other = Number of living units:_=.,__:______Number of,bedrooms_1__ Garbage Grinder___-___ Lot 5ize____1 ��' -�---------_._____________�___ Water Supply: Public System and name: ----.-- ----::- .'--- - -- - -- ------ ------- -----------------------Private 1 . 117%J . soil to a depth of 3 feet: Sand,❑ Silt❑ Clay ❑ Peat ❑ Sandy'Loam ❑ Clay Loam f�i' I ""� Character of 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 public sewer is available within 200 feet,) PACKA TREATMENT [ ] SEPTIC D .. Size S"/-- :'/�' ---- -----:-------- -- ------Liquid Depth.--- r�� --"----- 6--/7- Capacity-_vb-___ - ypiah!#-----•--- Material_ ----:--No, Compartments--------- _. --------- -. Distance to nearest: Well-__! ____ -------_------Foundation_s ------ --------_Prop. Line , i ! ...... :� - - __ __-;_-- .'D' Box___1-__ Type Filter Materia __ _____ -Depth Filter Material '_.l-: __�f_.------ ---- __ Distance�to nearest: Well_ _ ��` Foundation # p `___.______ --- -.- _Property Line __ �� SEEPAGE PIT - _ ' P s I� ; Depth- -Diameter_. __ ____Number___.__ _ __ ' Rock Filled Yes No t Water Table DeptFi- - -- -----------' Rock Size.---(-/-t{ el 4 ' - -- ; Distance`to nearest: We11,- -�_7D___:" ' ' __ Foundation__; _�.-r�� ":Prop. Line------------2�-�+__ . t -- -- REPAIR/ADDITION (Prev. Sanitation-Permit#_- ___________________ ______ -- -----------___:.'Date-- Septic ate:Se tic Tank-(Specify Requirements)---- - - - -------= ---------= --- ------.-_ , _ _-- f ; 14 Dis#Posal Fied fI PecifY Requirements); _ = -------------------'------------------------------------- - t1 t �= -----=------------=- ------- ------------------------ - ----------------------- -- e t (Draw existing and required addition on reverse side) f ' I hereby certify that I have prepared-this�appI!cation--and that-the :work will -be-done•in accordance with San Joaquin County Ordinances, State Laws, and Rules;and Regula#ions of:the San Joaquin Local Health District, Home owner or licensed agents signature certifies the Following: $ "l certify that in -the rforritance of,the�`o'rk' fol which this permit is issued, 1 shall"not employ any person in such manner as to-becom subject t orkma 's Cam nsation laws.of California.".. ) ; k .. 4 Signed----- ---t L-_ -- - - ---Owner ..._- . .,,z , BY F = --.- -- -- .. . Title- -�• -------- (if , } other than•owner - } FOR DEPARTMENT-USE ONLY: APPLICATION ACCEPTED -----------------------------DATE. 7- •------------- ---- DIVISION OF LAND NUMBER._ - - - - DATE-------- ---------------------------- - = .�,._..�.. - -._ _- .�,. ADDITIONAL COMMENTS----------------`--�----- '-------------- -- - - -- - -----------_----------------------------------_----_------ -------------- _ ----_---_ _ _________________________________________ __ Final-Inspection by: - - -:Date--- ----------------------- EH - ---------= -----EH is 24 S JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M i