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FOR OFFICE USE: ( FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............ ----------- Permit No._7j � -� � -.��- � (Complete in Triplicate) -�l Date Issued. -�/-. ....................... 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 beret described. This application is made in compliance wit l}8ontyOrdinance No. 549 and existing Rules and Regulatio � JOB ADDRESS/LOCATION,--- --- ---------- --- --- -- - - - - - CENSUS TRACT---- -- Owner's Name.....-C.L . itsGc( - Phone.t;�6./.zFi_.5..��---- Address---- -- - Zip ........... ----- CitY - - Contractor's Name-__ �..._._ � sl _-..__...-.-_.._-_._.-License �.__._ ffpl Installation will serve- Residence ®—Apartment House ❑ Commercial ❑ Trailer Court t it Motel ❑ Other----------------- ----- -------------------- Number of living units:-----/........Number of bedrooms.._-�V---Garbage Grind&r------------Lot Size_.___ ---------------- ------ Water Supply: Public System and name------ ----------- ---------------------- ------ ---------------------------------- ---------------- ----------------------- - -Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,% O Hardpan ❑ Adobe ❑ Fill Material_ ---------If yes, type-------------------------------- (Plot ._...............____._._.(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 L I- Size- Z' //,,,, ---- -- ----- -----------Liquid Depth. •,� - ------------ Capacity - ------- Capacity---A4P------TYPe.--/�� ---------Material.....C04_-:-------No. Compartments-_._Z ----------------------- Distance to nearest: WeIL._...��_ ........................Foundation._ _--_._..__.__Prop. Line.. /....__._.____ ® CJ LEACHING LINE [�J' No. of Lines....------------------- '__________________Length of each line.._.____._______...______.Total Length __ _ __ ._.____. _._.- ._.__ _ it D` Box_../U...Type Filter Material_��._�Z__.Depth Filter Material__..__o�_..-..--.-._....................................... .. r � Distance,to nearest: Well____ll5_________--Foundation.-----. _/---------Property Line------ --------------- SEEPAGE PIT Depth__�S__ .Diameter__. Z_-------Number------------ _____ --------- Rock Filled Yes [ No❑ Water Table Depth----------%-0-----------------------------------------Rock Size----- -�'..X./It --------------------_-- Distance to nearest: Well_.._�� ._._..............._..._Foundation.. S___._.___.Prop. Line..7 -_._._..... -- - . REPAIR/ADDITION (Prev. Sanitation Permit#._- ..... ........... ------------------Date--------------------;__._-_...____--._. I Septic Tank (Specify Requirements)------'------'--- ----- DisposalField (Specify Requirements)-------------------- - ------------------------z------- ------------------ -------------_-------------------------------------------------------- ----------------- ---------r------------------------------------ ---------------------------------------------------- ----------------------------------------------------------------------------- ------ ----------- --I---------------------------------- L__� (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, 1 shall not employ any person in such manner as to become s7 ytoWkmZan's Compensation lawsof California." Signed___ _ Owner - - ---------------- --------- BY `� - ------------- --------------- -Title---d �.-- -`-\`5�s'`c ----------- (I other than owner) FOR DEPARTMENT USE ONLY ll APPLICATION ACCEPTED BY.--I---- ---- ------------------------------------------------------DATE _7--! ��7_ ---- ----- - -- DIVISION OF LAND NUMBER ------- ----- ---- -- - ----------------------- .. ......DATE.--- ....._... -- . . .. --- .. .. ADDITIONAL COMMENTS- --------- ------------------------------------------ ------------------------- - ------- --------------------------------------------------- -------- ----------------------- -------- --------- ----- ------------------------ --------------------------- -------------- -------------------------------- --- -------------------------------------------------- --- ----------------------------- ---------------------- --- ---------------- -.. . Final Inspection by:---------- _ !2_ fic- Date. --- - --,. -__..—��...-- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M