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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -7 _ Permit (Complete in Triplicate) ----------------------- ----- ------------------------- Date Issued_- f-/--�'?7 ______________________ _______________________________ This Permit Expires 1 Year From Date Issued E 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 No. 549 and existing Rules and Regulations: JOB ADDRESS/1- CAT ION..,�?-S ...... ------------ ---- ---- ------.CENSUS TRACT --------------------------. Owner's Name l ; x-�'.�I = --- Phone- - ` � , Address------------/ = -� City-- ZiP - Contractor's Name ---- C ----- License # �� Phone Installation-will se e: h Residence-- Apartment House'❑ Commercial ❑ Trailer Court ❑ Motel .❑. ..Other-.---=--- Number of living units:-----�_-------Number of bedrooms—_ "`Garbage Grinder_____-_____Lot Size___..__ _. -r-- Water Supply: Public System and name--G------------ ---- --------_--- --.--- ------------ ----._.----'---------------------------• _ -----------------=--Private ❑ Character of soil to a depth of 3 feet: /Sand ❑- Silt;❑ Clay ❑ Peat ❑.'"*Sandy Loam El Clay Loam ❑ r #_r Hardpan [ Adobe❑ Fill_ Ma#erial.-!------ If yes, type------------------------ ------ I ♦ r l {Plot plan, showing size of lot, location of system in relation to'wel.[s,_.buildings,,etc.-must be placed on reverse side.] NEW INSTALLATION: (No'-septic t6k or seepage .pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ["] 'SEPTIC TANK [ ] Size--e% ---Z_____ ._'�_ _________________Liquid Depth._.______ ______.___.__.__O Y Capacity TYPe _Material---- -� .No. Compartments------�---'----:-'-------- Q Distance to nearest: Well--:-------------- ------------------------ -------- -------- -----Foundation-----1_V-___-------._Prop. Line- ---- -----. r LEACHING LINE [d] No. of Lines-- _--;;�-------------.Length of each line--------` -p----.---_.____.Total Length ___.________.___ 'D' Box-------J....Type Filter Material:---r _ Depth Filter Material.-------1_ ---�------------------------------ --------------r, 1 Distance to nearest: Well______ ------------Foundation--.- ___l.__--_-__.Property Line.--------- --------- ___.__.__-_ SEEPAGE PIT [vj/, Depth___ 3�! Diameter_�___..S.3. --Number.__ ------ate_________-_-_____ Rock Filled . Yes [Q No ❑ J/ Water Table Depth--------- _c _.__________' - ------------------Rock Size._- _-- __-- Distance.to nearest: Well---------:-1_�)-a�---------------- ----Foundation------ -Q-- ---.-__--.Prop. Line-------- ------ i REPAIR/ADDITION (Prev. Sanitation Permit#--=-----------------------------------------------Date-------------------- ---} , Septic Tank (Specify Requirements) - -- ---------- DisposalField (Specify Requirements)-------=-------------- ---------------------------------------------- ------ ------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------- ----------- ------------------- -----=------------------------------------------------------------ ------------------------------------------------------------------ (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 Workman's Compensation laws of California." Signed--------------------------- -------- ' ----- - Owne r -.BY Title__ , , f i (If other than owner) ' FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY -------- -------------------------------------------------DATE.----- -� ? ----------'--------- - . --- DIVISION OF LAND NUMBER.-- .6 --'-DATE ------�-----=- ------ ADDITfONAL COMMENTS---------- --- ---- - ------------------------- 3 ==- ------------------------------------------------- --------- ------------------------------ --------- . --------- ------------------------------------------------------------------- ---------------------------------------------------------------- er-------------------------- _. - ------------------- Fin Inspection b - - Date.- /-.-7,,---- P Y=-. , --- --------------------- --------- --- EH 13 24 SAN JO QUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M _ _ i