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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ ------- ---------- --------- Permit No._.77' 3"7 (Complete in Triplicate) -------------------- ------------------------------- --- '� - Date Issued--..___`�' 7 ----------- - 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 tom ((ante rrhC u ty.9rdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION------ --- ----18 ------- CENSUS TRACT..---------------- ----- -- Owner's -- ---- JpzFe r------------------ ---- ------------------- --- ------------Phone-- --------------------------- ------- Address-------- 11-0- �Mo-------S&CLl Q------------ -----------------------------------City-5 ! -------------------Zip 4 Contractor's Name--- ----r^.74 -Cell. I, -�-�---- - ------------------------- License #,V2' s Phone Installation will serve: Residence ;& Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--=------------------- ----------------------- ,�j 7 �' Number of living units:_.-/---------Number of bedrooms_` Garbage;Grinder---------.--Lot Size.-----rte. ------------------------------------------ Water Supply: Public System and name------------171 lwp-------- r--- - ---------------------------------------------------------------- -------------Private ❑ ---c Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ I Hardpan C� 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 [ ] Size-----------------------------------------------------------Liquid Depth ------------------------ Capacity_-------------------Type_--------------------Material--------------------- -----------------------Capacity---------------------TYPe_--------------------Material--------------------- ----No. Compartments------------------------------ Distance to nearest: Well ------------------------------------------Foundation.-------------------------Prop. Line----------------------- V LEACHING LINE j ] No. of Lines-----------------------------Length of each line.-.----------------------------Total Length._-.-.-----------------.--- 'D' Box------------Type Filter Material--------------------Depth Filter Material---- ---.------_------------------------------- i t Distance to nearest: Well-------- ----------------Foundation_.___.--------------.- ----Property Line.-.----_______---_--- r SEEPAGE PIT I [ ] Depth--- ------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No WaterTable Depth--------------------------------------------------------.Rock Size------,----------------------------------------- Distance --------------- --------------Distance to nearest: Well-------------------.-----------------------Foundation--------E---------------- Prop. Line------------------------ REPAIR/ADDITION ____.------ .- REPAIR/ADDITION (Prev. Sanitation Permit#----------_-______----- .---------_.Date-------------------F.----.---.--------------.-[ Septic Tank (Specify Requirements)----- ----------------------------------------- ---------- --------------------------•--------- Disposal Field (Specify Requirements)------ Q /� ,r�i/1� ......,wpe------------------------------------------------ ------------- --- ----------- --.:----------------- -------------------------- ------------------- ---------------------- ----------------------{.--- --'�o"----------'"------------------------".____-------------------.----- --------------------------------------------------------------.----------------------------- (Draw existing and required addition on reverse side) —� I hereby certify that I have pared this application and that the work will be done in accordance with San Joaquin County Ordinances, State (Laws, bno RJIes and Regulations of the. San Joaquin Local Health District. Home owner or licensed agents signature certifies the followi6.— r y "I certify that-in the performaMz*'of the worIV0'r`whi4i 0s pWrmit`is`issued, I shall not employ any person ih4uch manner as S ' to_ become subject to o loan.s' Compensation law $f California.''' , ! r . c. s I Signed /.1 er . I Title.-. --------------------- By------------------------- _ :..w.._,... a (If other than owner) i \L , F05 DEPARTMENT USE ONLY APPClCAT1`OIV`ACCEPTED BY_______'�. '77. — _ � � DATE. = _ DIVISION OF LAND NUMBER. �' �`•� ~= '= `_ '' .....DATE------ ADDITIONAL COMMENTS------------------- ---- --------------- ----- — .---t- -- - --- -------------------------------------------------------------------- ------- ------------------------------------------------------------------------------------ ------------------------------------ Final Inspection b -_--Date.------- '"-.`(- _ EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M