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FOR OFFICE USE FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i ;;V- (Complete In Triplicate) Date No. 7�" S%�•-• Date Issued 7-,,-7- 7,oP •••• i This Permit Expires 1 Year 'ram Doh Issued kpplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 'his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: IOB ADDRESS.'LOCATION �t L f`� L�C t c CENSUS TRACT Dwner's Name / k �r t r'> Phone 4ddress / r l 1<' C L City e. ,e& Zip Contractor's Name '�??r.�c'� % l: •- ; <e4 -eeo License #F �?F'7-J_J! Phone - installation will serve Residence ' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: number of bedrooms •3 Garbage Grinder Lot Size Water Supply: Public System and name _ Private Character of soil to a depth of 3 feet: Sand 7, Silt❑ Clay❑ Peas❑ Sandy loam❑ Clay Loam❑ Hardpan Cy� Adobe ' 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT '/ �l' ' X-s ' r ( ) SEPTIC TANK ( 1)" Size.� liquid Depth y � Capacity I&C e' Type `'t_t e e a ( t Materiol GK — No. Compartments 1 Distance to nearest: Well Foundation /C ' Prop. Line ..$ tq LEACHING LINE No. of Lines Length of each line C Total Length f Xe 'D' Box Type Filter Material S R, Depth Filter Material / 4 Distance to nearest: Well �� l Foundation l� r Property line .. SEEPAGE PIT � Depth Diameter �X r Number Z Rock Filled Yes No Water Table Depth j ��. _ Rock Size... ... ... .. ... . .... Distance to nearest Well Cr Foundation .!D...`_.. ..Prop, Line REPAIR/ADDITION (Prev. Sanitation Permit# Date _ ... ...... ... ... J Septic Tank (St+,!.;ify Requirements) Disposal tfield (Specify Requirements) - ........I•••.... (Draw ex,tring and required addition on reverse side) I hereby certify that 1 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: certify that in the performance of the work for which this permit is Issued, I shall not employ any person In such manner as o become subject to Workman's Compensation laws of Collfornlo." Signed Owner, y� By (if other than owner) FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY 4 �r j��, DATE DIVISION OF LAND NUMBER DATE ADDITIONAL COMMENTS r Final Inspection by rl`��• f� Date '-65 21677 REV 7/76 3M F.- rt :• •': JOAOUIN LOCAL HEALTH DISTRICT