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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .7_�_� 7�_ .�� ------- - - This Permit Expires 1 Year From Date Issued Date Issued._5,—"- 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 aw,existing Rules and Regulations: JOB ADDRESS/LOCATION-----� ._ ID_ _ r/ �� ----- '----- CENSUS TRACT./ L -.. Owner's Name y�� j - `•� ------------ - -- ._... - - - Phone2o %F, -' Y� Address />aiT-`.�- ---- �c Y H p ?' --- -- i - __Cit _Zi .. Contractor's Name1� __ � License # ,� / Phone. Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other-_._ 1 - Number of living units: _ Number of bedrooms_,,�---Garbage Grinder__ 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,�r ( �'1 Hardpan [-] Adobe ❑ Fill Material _ _ If yes, type __ _ __- O (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 permittecT-iT-public seywer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size __ _ _ Liquid Depth Capacity _ Type _ -Material No..Compartments Distance to nearest: Well _ _ . ._ _..Foundatjon; ---- t------- Prop. Line LEACHING LINE [ ] No. of Lines Length of each line ...._-_ "' - g ...- _____._--Total Length . 'D' Box Type Filter Material _. Depth Filter Material --_ Distance to nearest: Well _ _ Foundation Property Line- SEEPAGE PIT [ ] Depth _ __. Diameter _ Number _ . - --__ Rock Filled Yes ❑ No Water Table Depth -- - _-.. Rock Size Distance to nearest: Well - . _ ._- --__-_. Foundation_ _ __. Prop. Line REPAIR/ADDITION (Prev, Sanitation Permit#. __ . ------------- .__ Date- Septic Tank (Specify Requirements) _-- -------------- Disposal ___Disposal Field (Specify Requirements)-- .. .12 (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 Compensation laws of California." Signed --- _Owner - /ls�c� _ Title L � =- Apr-` ' _ - (If other than owner) FOR,DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- f ' - -- DATE J ------ DIVISION OF LAND NUMBER.-------- - - - --- -- ---------- - DATE .. - ADDITIONALCOMMENTS_ -------------------------------- - ----- --------- ------- --------- --------------------------------------------------------- -------------------- ------- -- - - - - -------------------------------- ---------------------------- -------------------------------------------------------------------------------------- -------------------------------------------- ------------ ------------- ------- ------------------- --------------------------------------------- ---------------------------- ----------------- ----- ---- --- ---------- -------- = - ---------- Final Inspection b i P Y ------ 1 - ----------------------------- ------- ---- --- ------ ----- Date.l_ --'__'_Z_S___2_1_677_ - - --EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT REV. 7/76 3M