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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No..779=--70� -------------------------------- Date I ssued_Y-_/g-=7 9 _----..___--.--_- ------------------ This Permit Expires 1 Year From Date Issued Application is hereby made to the Son 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: [� ---------�'--------------CENSUS TRACT--------------- - ------------- - ADDRESS/LOCATION 7 9 - ----------------------------------------- Owner's Name. t Phone --------------------------------------------- -------------- ------------------- - - - ---- Address '�1. ---- Ci •---------------------Zip------------------------------ 2----------- ---- r� +v Contractor's Name d -= ✓ C �ea--------License #- - - - --Phone --------------------- ---------- Installation will serve: Residence P?"'Apartment House E] Commercial ❑ Trailer Court ❑ Number of living units:__- Motel ❑ Other-----------_----------------..__--.------____ g rf--__-_Number of bedrooms...._.----Garbage Grindex_.._------_.Lot Size.1-7.4------ ---"---LCIS-------------- - -- Water Supply: Public System and name----=-------- --- - - - ---------------------------------- ----------------------------Private ❑ Character of soil to a depth of 3 feet: Sand E] Silt El Clay F1 Peat❑ Sandy Loam E-1ClayLoam El Hardpan F-1LT Adobe J 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 r__s eage pit permitted if public sewer is available within f PACKAGE TREATMENT SEPTIC TANK [� S` e % Liquid Depth _.-" /----------- CapacitY ` No. Compartments------3 ------ - : Well. _"_ .----_ - Foundation_.---_-1J--_____---._PrDistance to nearesti op. � Line--------------------------- 3 i LEACHING LINE [� No. of Lines-------- ------.Length of each line,_ 0-- ---------Total Length.---fe�.�".___.__.--"--------------� 'D' Box-----1------Type Filter Material------S--R-----Depth Filter Material.------f g------.---------------------- ------------------- Distance to nearest: Well-------`--�--"-----Foundation---------`---- -----------Property Line------5--------- .2 ----------------- / [ N ❑ SEEPAGE PIT [� Depth_ _rDiameter._-__��_ __.---.Number--------------------- -------- Rock Filled Yes o Water Table Depth------------- --------�------------------------Rock Size --__ --___ Size--- --- ------- ------------------ 6 - -"-___- i i dation.---- ------------Prop. LineQistance to nearest: We ........ Foun REPAIR/ADDITION (Prev. Sanitation Permit#_..-----'-_-i.=-"-----------------------------------Date-____-------.-"_.---------.------------------1 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 become subject to Workman's Compensation laws of California." Signed---------------- ------------------ ---- -- ---- ---- - -------- az tiOwner BY - Title ---'-1-jzt7o'---------- ---------------------- (If other than owner) O PA MENT UA 0 L APPLICATION ACCEPTED BY-- ------------------- --------------DATE.------- - (--- --7----- ----------- A DIVISION OF LAND NUMBER------ ---------------------- -------- 7 --- ------------DATE."----------- -- -------------- ----- ADDITIONAL COMMENTS ---------------------------------- ------------- - ------------------------------------------------------------------------------------------------------------------------------------------------------------ - �� ---- ----- Final Inspection by:--- ---------------------------------------I------------------ -------Date--- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M