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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ��`` .: --------------- ----------- ------------ -- (Complete in Triplicate) Permit No...?7-- ----------------------------------------- --------------- a:1--77------------------------------ - ---------.-----------.-- This Permit Expires 1 Year From Date issued 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: r7da c . JOB gDDRE55/LOC .._ _ "l - �•� -= Y ------------- CENSUS TRACT ~� - ---- Owner's Name _ - -Phone -- -60 S, j - ------------ --- --------- Address- lr�.__�L.l�i� _ Contractor's Name------- ...... -- _ --- - _. ---------License #-: ?l ' ,, --Phone-- •-------- �/�- Installation will serve: Residence ❑ Apartment House❑ CommercialX Trailer Court [❑ ....- �........., Motel.❑.. -.Other-_`------------- ��'�; ---------- Number of living units-----------------Number of bedrooms- Garbage Grinder------------Lot Size- __- �� f � 1 - -- -- WaterSupply: Public System and name---------------- G�- ---L --_ ------------ ---- ---------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ 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 public sewer is available within 200 feet,) •� �/ i PACKAGE TREATMENT [ ] SEPTlC TANK Size_ i�+_X`,5. _��.--- -----------------Liquid Depth---f/-----------------10 t� /r� Capacity- ____---Type �_L_----------Material_.--------No. Compartments---------0'-----------------0 Distance to nearest: Welf._--_--_ .-_ Foundation.-/G--____'_______._Prop. Line--- S______----------- r A F / LEACHING LINE No, of Lines----_-/-------_-----...Length of a ch line-- $___________________Total Length ---- --------------------------- JAI �� `, el 'D'.13ox------------Type Filter Material----------------�- _ epth Filter Material------�Q----._-----------------------------------------.40, � Distance,to nearest: Well ____ _________-- ----.Foundation--.-R20------------_-Property Line----------.-----------.--._---- -� a SEEPAGE PIT [ Depth p 34---------Number-------- ____------------------- Rack Filled Yes' No Wa#�rTable`Depth f Q ----------------------- Rock Distance to nearest: Well--....---./ "-----------------Foundation f- -`r+_.--------- Prop. Line___- ------------------ REPAIR/ADDITION (Prev. Sanitation Permit#------------------ � Date-------------------------------------------- -- Septic Tank (Specify Requirements)__.__-.__--: _ — —. ------- --- ---------------------------• ---------------------- ----------------------------------------------------- { Disposal Field (Specify Requirements)----- ------------- - ---------------------------------------"I ------- ------------------------------ ------------------------------------------------------------ ' ----------------------------------- -------------------------------------------------------------------------------------- -------------- --- ------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application aQ 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: l _ G "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 su ' to Workm Com nsation laws of California." , Signed------- --+-- ------------------- ------- =Owner By------------ --------- I��/'�• f �`� Title --------------------------------- ------ --- (If other than owner} . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- - - - - - � - -- --------------------------- DATE )a DIVISION OF LAND NUMBER - DATE. ------------ ------ -- ----------------------------------------- ADDITIONAL COMMENTS__- ---.. � �_________________ ----- ----- ---- --------------------------------------------------------- -- ---------------------------- - ----- ---- ------------------------- Final Inspection by;--.-- Date ` �- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M