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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------- --- ----------------------- -----------= Permit No._77--_ -- (Complete in Triplicate) -------- ------------------------------------------------ - � 'r,°° D !/� / ! Date Is 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 compliance with County Ordinance 549 and existing Rules 9nd Regulations: JOB ADDRESS/LOCA ON-------- - CENSUS TRACT 9t 3� ..... Owner's Name. =--A.._ " " _ ": _ _. -. -----.- Phone_- ..-. r---------------------- Address---- - .� --� ►u- -:---- --------- ------------------ ---------------:City ---- ----- ----------------Zil------------ -G-- Contractor's Name___.. �G `5 �G/ License # .�1'S ' .Shona Installation will. serve: Residence g----Apartment House ❑ Commercial ❑ Trailer Court ❑ i / Motel E] Other: -------- - " Number of living units:.-:..../..------Number of bedrooms__ -_Garbage Grinder------------Lot.Size...... .. ...............................-------.____ Water Supply: Public System and name---------------........� . ! -----------------Private Character of soil to a depth of 3 feet: ' Sand ❑ Silt�❑ Clay ❑_ Peat EJSandy Loam E] Clay Loom E] Hardpan Adobe F-1FillMaterial.............If yes, type-----.______------------------ l , (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 perritted�if public sewer is available within 200 feet,] , lie PACKAGE TREATMENT ['] SEPTIC TANK '._ -SAi�ze-.- --.� -— -------- Liquid Depth. ------ ------------- Capacity-/ PO--- ---Type- -��'�C___MatwiaE No, Compartments---------oZ.---- --- -- ----ir Distance'to nearest: Well_.___- ---------------------- Foundation. ------------ -----Prop. Line...__.. .---.----- � r r r ! O[ � r LEACHING LINE [t.}r No. of Lines_----J - -------------Length of each line.7_d--ya__°yQ Total Lerig'h _...----------__--- :l - .. ate ._.��._..,�G/1. Material ra --- ------------------------------------- D' Box__.__ ..... Type Filter Mater�l -- - 1L�.Depthp filter Q --� � L� ------------------------------- SEEPAGE r , . . Distance.to nearest. Well_____.s�................._Foundatio --'--_-!._Property ne--'-s�---------- ---�---- ---� SEEPAGE PIT Depth.-_ ., .-...Diameter_.3 v� .- �___-- _ _ _ . - Rock Filled Yes No ------Number ------ - ,r ❑ Water Table Depth--------/ 8 ~- ' ----------------=-----Rock Size- q-�'w--------------'----------------- Distance to nearest: Well------14.4- ----------------------Foundation-,._6.4--------------Pro,p. Line--- ------------------ t REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date---------------------------------------------- Septic ---------------- ----------------------------Septic Tank (Specify Requirements)-------...--z. =_------ -------- — —._ ----- _-------'---------------- ---------'--------- ---------------------- ------ . Disposal Field (specify Requirements)----,"--------------- ------------------------------------ - -------'- -------- ------------------------------ ----- -----I-------------------------------------------------- -------------- ---- -----------------=----------------------------=--------------------------- --- ------------------------ ----------------- -- ------------------ ------------------- ... {Draw existing and required addition on reverse side) I hereby certify that I have prepared this app lication.,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: r "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 W etan s. Com ensation laws of California." Signed----------------------- -- + _. ... --- --Owner BY---------------- - - --------;------------ Title '----------_-- r (If other than owner) N. FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY ------------------------------ ------------------------ ------------------------ DATE..-\1" -'-� -------- -------------- DIVISIONOF LAND NUMB --- --- -------=----------------' - ------------------------------ -------------DATE---- -------------- -------------- ------------- ADDITIONALCOMMENTS---------- ---------------------------------------- ---------- ------------------ ---- ------------------------ ----------------- ------------- --- ---- -- ----- ----------------------- --------------------------------------------------------------------------------------------------------- ----------------------------------- ----------- -- ------------------- -- ------- ----- - Inspection by. " = _ % Date Final Ins12 -.. P FH 13 24 SAN JOAQUIN LOCA HEALTH DISTRICT F&5 21677 REV. 7/76 3M