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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No...7................. ! --------------------------- ------- --- '2 Issued_�_`. __�� --------------------------- ----------------------------- This Permit Expires 1 Year-From Date Issued _Application is hereby made to the San Joaquin Local Health District for a permit todconstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:. JOB ADDRESS/LOCATION 1-� 1 -Aa---,� ,,14_121-------------------------------------------------CENSUS TRACT 9d�_. _. Owner's Name-e,41�4)C't4 .+C.G_!J_1 -------- -- -------------------------------------------------------Phone ... J i _ 7-- -- Address i7 z $ l` 4 P �--1-------.- - ----.------ ------------ City-----1 oM_ --------------------Zip_�i��37---------- Contractor's Name__�� --.� i _ eu __ A-- - ---1---------- License #---c �•S.)s ---------Phone___c�6F3f ---.---. i Installation will serve: Residence ❑ Apartment-,Hou `•.❑ Commercial ®W'railer Court ❑ t i r Motel Elr Othi"ery ------ Number of living units-----------------Number of bedrooms_.___6-7_GAage Grinder.!`___ `Lot Size---- S_----------------------- Water -___- _____._.Water Supply: Public System and name `------------.. `fl�----------- �� . Private Character of soil to a depth of 3 feet: Sand [:] Silt r! Clay Peat o Sandy Loam ❑ Clay Loam ®� Hardpan ❑ Adobe ❑ Fill iMaterial_ _.---If,yes, type-------------------------------- ' (Plot plan, showing size of lot, location of system in rel-dtion to"w" /ells/buildings, etc. must be placed on reverse side.) 6 NEW INSTALLATION. (No septic tank ,or seepage-)pit permitted if public sewer is available within 200 feet,) j i -S PACKAGE TREATMENT [ ] SEPTIC-TAN'K—[--j"_t 1j Size-'------"-------i'--/__ __` -----,---I---------------Liquid Depth-------------------------� Capacity`---------------------Type------ ,f4 ?------Material----4--------------------No. Compartments-- ------------------------------ t Distance to nearest:.Well-I-------•.---- '�=----------------- •Foundation--------------------------Prop. Line--------_------ ------_-'-- LEACHING LINE ['] No. of Lines..---.` -- ----- Length,of etch line.._._____1____________.____I.Total Length._.._______________________________ _ D' Box------------Type Filter ffNatenal ______ ________Depth Filter Material-------------------------------------------------- ----------- Distance to nearest: Well17.__.____________.Foundation__ ________________________.Property Line_._________________.________.___._- SEEPAGE PIT [ ] Depth._._A____.__.__.Diameter__________________ m>je'r._____________.__`�____ ______� Rock Filled • Yes ❑ No ❑ # Water Table Depth-------- Rock Size « ., 1 � ` Distance to nearest: W@I_._.__.__- ___ W"'""`�_____ .-a_Foundation-----------------_---------Prop. Line----------- ------------ -1-i [ REPAIR/ADDITION (Prey: Sanitation Permit#-----------F"--'---------------------------------Date-------------------------------------- ------- Septic Tank (Specify Requirements)----- -------------- --Y --- -------------=------------------------------------= _---- ----------E------------- ------ ! tI p ( P Y. q -- -----V 4�'f- hi4¢L i ----o--- ---------7.�---- J Dis ---- Disposal Fiel S ecif Re uirements}--._.__..sr[ -_ 1 IR-57-1 _ ________________________:_______-________ --------------------`--------------------I- -------.---.---_----------`----------------------------------------- � _______________________________________________ .--------------------------------------------------------------------------------------------------------._------,________.____.__.._____________._._____ 1 (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 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 to become subject to. rkm n's. Compensation laws of California." Signed--------------- --- - ------ ------ --- -- Own ern 1 �f' ------ --------=---------- -- Title -- --- - ...'--+--- (If other than owner) FOR DEPARTMENT USE ONLY- APPLICATION ACCEPTED BY------- ------------------ ----------------------------------------------------.....,.DATE -------------- i ,. DIVISION OF LAND NUMBER ____________________ DATE------------------------------- ADDITIONAL COMMENTS--------------------- -- - ------ ------------------------ ------- ------------= -------------------------------------------------- --- -- ------------- ----------------------------------------------------'------------------------------------------------ --------- ------ --=---------- ------------------------------------------------ -------- < ---------------------------------------------- '------------------------------------------ ---------------- ---------------- ----- ------------------------------------------------- --------- ----- Jonby = ------------------------------------------- Date. ? ----- ------------ ----- / V / SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M