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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- J Permit No.79--��- , ;(Complete in Triplicate) ---------------------- ,. Date Issued-7._1 =-Z1 ----------------------------------- 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 County Ordinance Na.,549 and existing Rules and 4 i Regulations: CENSUS TRA CT-------- -- --------------- JOB ADDRESS/LOCATI --- ---- : h4 Q Phone ' --- City - ----- -- --------- Zip------------------------------Owner's Name �Address------------ -- Phone Name iContractorLicense �.. Installation will serve: Residence [ Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel`❑ Other---------- ----------- �• r Number of living units------ -- ------Number of bedrooms-----y_.Garbagt a Grindert._= ------Lot Size------------ -----------------------.--------------------__._- Water Supply: Public System and name---------- --- - --- 4--- ------------ -- -------------__. ------------- - Character of soil to a depth of 3 feet ----------Private a • Sand EJilt E]SClay E] Peat [D Sandy Loam EJ Clay Loam El,.. lt Hardpan Adobe ❑ Fill'Material- .--`_.--If yes;tYP?� t I -- (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 W"PI ` age pit permitted if public{sewer is a'vailabl'e within 200 feet,] A Size-_ (s -.`_. :i, -- ------- ---'- ---Liquid Depth._ ._ PACKAGE TREATMENT [ ] SEPTIC TANK'�j { -- Capacity TYp ---------------- ------------ Material__ ----- -No. Compartments--- --2- �-----------W4 -G.L!(1 f - --- Distance to nearest: Well- --Y-•-� r -------- =.i..•.Foundation=-- /-�T f_�--------Prop. Line-- ` ---------------- T LINE' [ ] No. of Lines ___ Length of.each lines - :Total Length -------------------------------------- LEACHING -- i s i D' Box- Type Filter Material --------Depth"Fi[ter Material---------- ------ -------------------- ----------- ------ ? 'Distance to nearest: Well---------'--------------------Foundation---`------------- --_---.Property Line--:---------------------- t Rock Filled Yes E] No E] SEEPAGE PIT [ ] Depth----,-----------Diameter.------------------Number- ---tr_--.______-----.--- jWater Table Depth- - = -----------:Rock Size'----- --------- ----------- Fob Vdat ion'- Line Distance to nearest: Well------. ------ --- :---- un - Prop. REPAIR/ADDITION (Prev. Sanitation Permit#-----_" =---------------------- Date_-- ----1 Septic Tank (Specify Requirements)-=---- - ------------- --------------------------- -------.-------- -------------------- i Disposal Field (Specify Requirements)-- ---- --- ------- ��"�'� n --------------------------- - ------ rte..---: -------- - - - - ---- -------------- ----- --- --- I ------------------------------------------ - - J� Draw ezistin nd r-e uired 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 Ordinances, State Laws, 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 this permit is issued, I shall not employ any person in such manner as ki to .become subject .to Workman's Compensation laws of California." k Signed--- --- -- --- - ------------ = --s -------- Owner . Title__ -------------- - ------------------------------ BY------------- ----------------------------------------- .-- ---- - ( e'r than owner) ------ --.--- if oth • ' FOR DEPARTMENT USE ONLY g APPLICATION ACCEPTED BY_-_-- --- DATE._-- --.'�--- - ----------/-- : -- DIVISION OF LAND NUMBER ------- -------------- -- ------.DATE -------------- ---------------------------- --- -------------- ADDITIONAL COMMENTS------------------- ----- - -----:---------------------- -- ------ 4 -------- ---------------- ---- ------------- ----- - ----------------------------- '-- -_.___ i Final Inspection-by: Date------------ ---- �- ----------------------------- ----- - - - -------- --- - - -------------------------------------- - EH 13 24 SAN JOA IN LOCAL HEALTH DISTRICT Fay 21677 REV. 7/76 3M l