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FOR OFFICE USE: FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT .(Complete in Triplicate) �'� Permit No....77 .7 � --------------------------------------------------------- �'�!w ' Date issued---� •---•----- ----------------------------------- This Permit Expires i 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 C9.ynty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION...-,F0,7 -------- -------- = CENSUS TRACT, `+ -.. ----- Owner's Name- a �7 - one = ---------- City Address -1 -- CityZi ---------- Contractor's Name. ----- _..- ----- ------ License #_ 1 39-----Phone-.'7��--- Installation will serve- Residence [impartment House ❑ Commercial ] Trailer Court ❑ k Motel ❑ .Other---------------- . ' 4 Number of living units:..--. ------Number of bedrooms---1_ ----Garbage Grinder------------Aot Size_ ,_ ------- d----_.-_,--------------- - 6 Com[/ Water Supply: Public System and name --.----.:- -------- -- -. ------ i _- ----------------------Private Character of soil to a depth of.'3-feet. Sand [] Si.lt.❑ 'Clay E) 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,) , PACKAGE TREATMENT [ '] SEPTIC TANK - f [ 1 Size --------------- --------------------Liquid Depth.-------------'--- -- ---- [ Capacity--- ------------- =Type - -- --------------,--Material------------------------:--No. Compartments------------------------------ ---- a.-.. Distance to nearest: Well P = = Foundation----------- .------Prop. Line-=------------------------- LEACHING LINE [j No. of Lines-- --.-`,----- .----------- Length of each line.-------- -------- ---------Total Len' th. .-------------------------------------- fBox--------- --Type Filter Material-------p_-_-------Depth Filter Material--------------------------------------------------------------- Dis A . s tante to riearest: Well----------___--- `_-Foundation--W':-:"""�""-:_ ----Property Line.-:.--_ ------.-.---_--- SEEPAGE PIT [ ] Depth----------------D.iameter--------------_-----Number------------------------------ Rock Filled Yes.❑ No ❑ `Water Table Depth----------------------------------------------=-----------Rock Size----------------------------------------------- ` Distance to'nearest: Well----------- -------- -----------.Foundation ---------------:---------Prop. Line------------------------- r REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- -----------------------------Date--------------------------------------- •____] Septic Tank [Specify Requirements) = Lq � ` ----------------- %' r --------=- Disposal,Field (S ecify Requirements) //l-Q- -- -- ------ - -- - - ------------- -----------------------/ '3--- ------- -------------- -------------------- -- ...................................................... --------- ------------------------------- -------------- [ (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work will be. done in accordance with San Joaquin County Ordinances, State Lows; 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 thisermit is issued I shall not p employ p y an y person in such manner as to become ub' ct to orkm n's Compensation; laws of California." Signed- - ithan�ner)Y------------------ --- - ------:-------- ----------------------- �Title----B - - ----- ---=--- -------- ----------- ---------------(If otheS FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B / DATE. Z_!f Z — 77 DIVISION OF LAND NUMBER------- ------=------------ ------------------------------------------------------------------------------ DATE..-------- --------- ------ ± ADDITIONAL COM NTS--_-... i - ------------ ---- -rte --------------------------------- -- --------------- --------------- ----------------------- --------------------------------------------- ------ ----------- ------------------- --- -- ------------- - ---- - ---------- -------------------Date--------- - EH 13 24Final Inspection b SA JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M