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FOR OFFICE USE: No,, FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 �,Z� ------------------ ----- -------- (Complete in Triplicate) Permit No._ .____�________ ___ Date Issued._F-�-7__77__- `"----------_.__-____-_-_-- ---- _ .- 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 Count Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ,��,______--- 99_..._____/T ----------------- -----C N US TRA '-�_1_.�11 Owner's Name c,,,,, `R/ -------------------•------ ----i--------------.Phone--------------- " /lLe c --------------- t Address-.--- ------ '� J--- �---- t om -------------------Ci £ zip _ ---------------- --------- ��s . Contractor's Name -:�-h- ---License --Phone ( - "Installation will serve: Residence,, Apartment House❑ Commercial ❑ T+Ier Court3❑ Motel ❑ Other--------- ------------- - ------ --- /} Number of living units:__._'.-..__--_-Number of bedrooms-__-_Garbage Grinder _.---_____L t S ie_ 7® Water Supply: Public System and name ---------------------3-------------------------------------- ---- Private )�'] Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy ar1--0•-.-.•-ClaywLoam ❑ HardparK Adobe i7r Fill Material__.._______-If yes, type-------- ------ (Plot (Plot plan, showing size of lot, location of system in re ation to wells, buildings, etc. m t be placed on1r' se side.) NEW INSTALLATfON: (No septic tank or seeo6ge pi{, permittbckif public sewer is available wi hin 20Q fee£) , C �� PACKAGE TREATMENT [ ] SEPTIC TANK `t. Size_. ------ Capacity] �::�------ --------------L ui Depth`��------ •- 11 ` Capacity.L____. __________Type_.Pti;rZ_�f-T.-_Ntgterial��1'l _'No. Compattments i�✓.___.__ • ,r •_:.,="'ate.. _ Distance to nearest: Well_6_ --—______ _Foundation_ ©_ --------- OF _______3=.,_Pro - ,t p- LEACHING LINE No. of Lines_ -------------__.Length of ea lips.___ �___---_--------------- + _ j r� �• t De th Filter Material '-j' - ` r s � i y. Distance to nearest: Well_6_0------------ _---q!-�_--_-_ Property_Line.__. } SEEPAGE PIT Depth7Diameter Number. _._ Rock Filled'.Yes`❑ No b,_ . .. _ . . ._/ ._ ..., _ - __._ w._, ��,,r� .. Water Table Depth !- ;r... . _----------------------- Roc Size - - t 7--- •j----------- Distance to nearest: Well--- --------------------------Foundation------ -------Prop. Line____- __r - - REPAIR/ADDITION (Prev. Sanitation Permit# _- -----------------------------------------------Date -------------------------------------------) -Septic Tank (Specify Requirements)------__ --_- Disposal Field (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 becorn subject to Workman's rompensat�,on laws of California." Si ned.. - BY - ------- Z5 By Title.. - --- - - ------------------ (If other than owner) FOR DEPARTMENT SE ONLY APPLICATION ACCEPTED BY------ ----------- DATE. =�-77 DIVISION OF LAND NUMBER. •. ------. DATE ADDITIONAL COMMENTS------------------- - - --------------= ---------•-------------- ---------------------•------------------------------------•-•--------------------------------------------•-----------••------------------------------------------------- -------------•-------------------•---•--------------------------•-----•--------------------•-•-----------------------------------•--•---------------------------------------•------------------------------------- ---- - -----------------------------_. --------------------------------•--------•-------------•--------------•---------------- - _ -------- Final Inspection by:---- 'F - - - ----------- - - -- ------------------------•---------Date---�.-•--------- - - - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M