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r� e } M1 M FOR OFFICE USE: APPLICATION FOR SANITATION PERMITFOR OFFICE USE: ------------------------------------------ Permit f (Complete in Triplicate) " Date issued._C�_l-_.77 _________________---------------_________________ ___ __ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with C unty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N._...r.:- ��-.-,_ ._ + CENSUS TRACT------ - ---------- - .- Owner's Name 4 �. Phone Ml �,�`� �d 9 Address--- CJ --- -- - --------I--------------------------------- -City .. .... ----------Zip---- ----------------- I SJ7Contractor's Name__._ � �-__ __________________License #.- !_./ _____Phone-__--- ---------------------- Installation -` �----,---- Installation will serve: II Residence Apartment House.❑ Commercial F] Trailer Court ❑ ❑ Number of living units:___ --------Number of bedrooms----/eC_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 E] 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 [ ] SEPTIC-TANK [ ] Size--------------------------------------------------- _Liquid Depth __________________ _ ------------------------------------ - - ------ Capacity---------------------TYPe----------------------Material---------------------- I-No. Compartments--- ------------- _---- W Distance to nearest: Well--------------------------------------------Foundation--_---_--=--___:---- -----Prop. Line-..,-------------------------Y LEACHING UNE [ ] No. of Lines----------------------------.Length of each line-------- -.-Total Length.--------------------------------------- T [ D' Sox Type Filter Material C Depth Filter Material--- ----------------------------------------------------------- Distance to nearest: Well-_--.--_-__ h Foundation- = Property Line SEEPAGE PIT [ ] Depth....__----------Diameter..,_----------..----Number_.___________ __.______________= Rock Filled Yes ❑ No Water Table Depth-_':----------------------------------=----- ` - Rock Size-------------------------------------------------- 1 Distarice to nearest:'Well_.'--------------------=--------- - -----Foundation-- ----------------.----- Prop. Line-------------------------- REPAIR/ADDITION {Prev.'Sanitation Permit#_______________----------------------- ----------------Date---------_____...________:_.___._..____.__._-_} Septic Tank (Specify Requirements)-------- = f ' --------------------- ---------------------------------- I Disposal Field (Specify Requirements)---- ------------- � r . ---------------- -- - ------------------------ -------------------- - --- (Draw existing and requiredadditionon reverse side} I hereby certify that1 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 Sari 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 beco lett to orkma 's Con of California. # P.)h Signed----- _4W?,- h - Owner Title_____"'__. _ - ----- ------------ ------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = = ------------------------- - DATE.------- 7f---------------- 'DIVISION OF LAND NUMBER ----------------------------- -- DATE °--- - --------------- - 5 . ,ADDIT.IONAL COMMENTS PE, j_.._ � 1 -- - -------------------=-------------- ----- - ------- "----- ----------------------------------------------- ------- ------------------- ------------- ----------------------------------- Final inspection by:... �Q- �_cQ� __-- �Cs;�� -- e-- --- ---- ---- ------------------------------ EH 13 24 ° "�� `f��p C 11N LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3m