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. r. FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- (Complete in Triplicate) Permit No.-77_-.73__1- ---------- --- ----------------- -- -- ------------------ Date Issued._�`l.�--71_ ------------------------------------ ------------------- 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 Coun y Ordinance No. 549 and existing Rules and Regulations: R JOB ADDRESS/LOC ,TION._,__._ ---- -- �] , ------------- ------------.:--------- CENSUS TRACT--------- -- - Owner's Name ----- j'.-- -- - -- -------- -- --_---------:------------- ---------- ---= - ---Phone------- ---------;:----------- ---- �7 -�-- Address---- - -- --- --- =------- -------------------- -----------------------------_ - -City- - - ---- - - ------ -ziP--------- ------- - Contractor's Name___ __--____. .___/`� _ _.._.._License #__a_1l`�� -_ Phone__ � � Installation will serve: Residence ❑ Apartment House❑ Commercial Trailer Court ❑ Number of living units------------Number of bedrooms_----_------Garbe a Grinder_._..._.__.__Lot'Size.._.! �Q. a � , ote Other------- = =` Garbage --- ___=h - Private, Water Supply: Public System and name------------------ ---- 1 - Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay 0 *`,Peat [_1Sandy Loam ❑ 1Clay Loam E] 1. i Hardpan E] Adobes 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.) s I` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} } ej PACKAGE TREATMENT ['J SEPTIC TANK P< Si e___��-�-�-1 ------------------- -------- - Depth I Capacity/ TYP MaterialNo. Compartments_.. 7 7 ' 'Distance to nearest: Well---=--------------,------:------ ,----.-Foundation_-40______._ Prop. Line---- -------------__ LEACHING LINE. oe ' ['^� Na. of Lines___._____ __.._____________ Length of each line.___ ®_________,___--Total Length _-_.._. ---------------- ------ _ • . -------------- 'D' Box------------Type Filter Material-5_r_/04-Depth Filter Material_____�_9-___ --- ------ �7 ' r ------------------------------------- Distances to nearest: Well----- _�______.=_:_'Foundation____=,�"U:___ _-.-Pr"operty Line---��_�-------- SEE PAGE ______-SEEPAGE PIT [�' Depth_1.4 .'____ terG' Number----------/------------------ Rock Filled Yes No ❑ P I----------------------------Rock Size--- --- � of Water Table Depth �- ----- --------------------- l e p— J .� Distance to nearest: Well___M------------- --------_-________-Foundation- Q----- -------. Prop, Line.__ --------------- ]______ REPAIR/ADDITION (Prev. Sanitation Permit#_________________________________________________.Date___ SepticTank {Specify Requirements} --- ---- ------------------------------ ----------------------------- ---------=----------------------------------------------------------- Disposal Field (Specify Requirements)-- ------------- ------ ------------------------ - ----------------- --------------- --------------- ----------------------------- -------- -- ----------------=----------- ---------------=------------------------------------------------------------------------------------------------------------- ------------------------- -- I ----------------------------------- --- ----------------------- ---- (Draw existing and required addition on reverse side) ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents i signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I small not employ any person in such manner as to become jet to Workman's Compeysation laws of California." ^ Signed � �-- ----- ---------------- ` Owner e BY--------- --- ------------------ --'----- n _ Title---- (If othePowner) - FOR + DEPARTMENT USE ONLY " "!r - '` �----------------------- --DATE ---------- �-1 F 1 APPLICATION ACCEPTED BY.___ _ __.___ ___ 7 �{---- DIVISION OF LAND NUMBER------------------ ------_K------ --------------------------- ------------------- DATE --- ---------- -- --------------------- ADDITIONAL COMMENTS---------- ----- - -- ----------------------------------------------------------- = -------------------------------------------------------------- ------ ------ -------------------------------------------------------------------------------------- ------------------ --------------------- ---- --- ---------------------- ------------------------------------------------------------------ 17�7--- ------------- Final Inspection by:_ -- - ------------ ------------------ -------------------------------- 9 `�� -- - - -Date.-------- - ------- EH 13 24 SAN JOAQUIN LOCAL HEALTH'DISTRICT F&s 21677 REV. 7/76 3M �,.. 7 ;