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FOR OFFICE USE: FOR OFFICE USE: �APPLICATION FOR SANITATION PERMIT �./ _..------------ --------------- No...77-. (Complete in Triplicate) Permit Date Issued.. -. ....................l ----------- ------------ ._... 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: JOB ADDRESS/LOCATI N_ - /tA..9---f4__/ �' �--------------___......-------.--CENSUS TRACT..-------------......-------- - Owner's Name_.. -'""�_- --- - — ----------------------------------- Phone-----------------------____ ----- Address --7/--3 - - ---------- City.- -- -- ---------------------ZIP-------------- ------ ---- r - - - Contractor's Name---- ... `-- - . - .-- -------------- --------- ---- --License # Phone------------------------------ Installation will serve: Residence [ Apartment House]] Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------- ----------- Number of living units:...--- ._-..Number of bedrooms....-Garbage Grinder.---____Lot Size-..........J ........- .._-..._-_-..._._-___ W 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 Er' 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 [ ] SEPTIC TANK I f Size Aj-�/X-9......._�.� / h , - / ....-- --------------.Liquid Depth.-- ------------------ Capacityj�Q�......Type_ ,;VMaterial.-_.�. ..... No. Compartments_..__ -.-..�.-.--._. 'fes"� - Distance To nearest: Well_ _ -_ -------.....- .....Foundation..---/ .14. . .---.Prop, Line-------- ---- ----------- LEACHING LINE No. of Lines__ -----a3------------- Length of each line.------- --------------Total Length r D' Box---- ._ ....Type Filter Material --- S ---Depth Filter Material_-._� ------------------------------------------ Distance ............... ....................._-_ Distance to nearest: WeIL.--!a0./..........Foundation......-./a f ----------------Property Line-------------------- SEEPAGE PIT [ Depth .-_Diameter..._3U-f..Number---- -------------, --------- Rock Filled Yes No Water Table Depth---------------yp-----------------------------------Rock Size---- .a?----.��+..-------------- Distance to nearest: Well......... _/-----------------Foundation----- . p..�---------.Prop. Line_..--. REPAIR/ADDITION (Prev. Sanitation Permit#----.-----------------------.................. ....Date_. -----.---_._------ __ -------___._------) SepticTank (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 Co nsation laws of California." Signed .... 01 Owner By.... ... ...---. ---- . . � Title- r ?� -t (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYL'. .. - - --- - - ------ - ----DATE .'7/- DIVISION - - ------- DIVISION OF LAND NUMBER . - - ...... --- - - - ..DATE ------- ------------------------------ ADDITICMIAL COMMENTS..... - ... -- -------------------------------------------- --- ----- -- -- _------------------------------------_--- ------- -- ---- . ... --- ---- ---------------------- - ---- - ---------------- --- -- ------- -- - - - ----- ------ - ----------- .......... ----------------------- -- --------------------------------------------- -------------------- ------- - ------ - - --------- ..--........ - - - --- - - f ,f IP-7 �j �J Final Inspection by:--------- - - ---Date----�L... w.... /--------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6s 21677 Rev. 7/76•••