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FOR OFFICE USE: � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - -------------- - ------ (Complete in Triplicate) Permit No.___7___'.__ .� Date Issued__-_�� 7 Im.._-._.__.--.-___ __ --------------- __ _ 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 No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOCATION_-0-0 1 - '-}- -------------------------------CENSUS C ( TRACT-------------------------- ----- Phone-Owner s Name � ? .. --p 7 Z Z 7.. —Address--------------- -- ---- '-----_ ----------------------------------City----- ---------------------------Zip---��Zpy a -- ^ �Contrpctor's Name------------- ----- __.-------.--- s_ 3-- - - _? ---- --_ - 0-Installation will serve: Residence Apartment House.❑' Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------------------------- Number ---------------- '= ------- -Number of living units:-----/---------Number of bedrooms----�----Garbage Grinder------------Lot Size__________ z___Qv--,_____________________ `Water Supply: Public System and name --------------------------------------•-----------------------------------------------------Private . Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ 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 perriiitte8 if public sewer is available within 200 feet,) "PACKAGE TREATMENT SEPTIC TANK Size,__�__ -_____ ( �-- ---------•-------_-_-------Liquid Depth[) 5• r -�--r- -------- Capacity__/A __.. Type-_ ._Material__-_ _No. Compartments______ _________-_-_-. _ Distance to nearest: Well-------------�dt--------.--- .Foundation------ Line-__` �e LEACHING LINE [�, No. of Lines-_.-_.--_______________Length of each line.__-__ _._______:____Total Length------ -J- 10----r 'D' Box---- ____Type Filter Material___ ___ __ _Depth Filter Material_--------f _____________________________________________. Distance to nearest: Well------*4�-v_117 ___.._Foundation___-_ -"-------Property Line._ ----------------------------_. p XS_"'o 3 ❑q SEEPAGE PIT De th__Za ____Diameter___ __ __ ______Number____._.... __________________ / Rock Filled Yes No Water Table Depth------------------------------------------------_____ Rock Size`,f-yell-- --- Distance to nearest: Well..._.._._..(_029-----------------------Foundation_.. Prop. Line.-5 / ___.___ . ._ REPAIR/ADDITION (Prev. Sanitation Permit#-.-_._______-_______________________________.__Date.. ........................................... ) —Septic Tank (Specify Requirements)--------------- ----------------------------------------------------- ------------------- Disposal Field (Specify Requirements)---------- -•----•---- --------- ---------•-•---------------- -- ---------------------------------------- r-----------------------------------------------------------------------------•-•-------------------------------•----------- -- --------------------------------------------------------- - -• ---------------------------•--------------------- (Draw existing and required addition on reverse side) 1 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: "1 certify that in the performance of Ae 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--------------------------- ------------ -------- - Owner .� By----------- / -fJ' `- Title x-1? _�.r ------------------------ -- ---- - ------------------ f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------DATE.--- - - 7- DIVISIONOF LAND NUMBER.--------------- -------•-•-------- -----------------------------------------------------------------DATE----------------------------------------------- ADDITIONALCOMMENTS------------------------------------------------------------------------------------ --------------------------------------------------------------------------- ------- r_____________________-------________________________________________________________________________________________________________________________ ---------------------------------------------------- --------------------------------------------------- !__--_-__..___ ____-------w- -- ______ __ _________.______._____________._____ .__._.____....________________.__._____^_.__._._________.. ----------------------------------------------'• ----- __ _._ _- ._ ___-- ---_ ___ ......__._._._______ --•---------------_---..---------------- _ / Final Inspection by: -----•------ -.�tr�L. ------- __ . .. .__Date__.________. "` EH 13 24SAN JOAQUIN OCAL HEALTH DISTRICT F8S 21677 REV. 7/76 3M