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FOR OFFICE USE: & ` 1:1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 77. .5 195^ Permit No-------- -- -------- (Complete in Triplicate) - 7 �� 7 Date Issued_____�...:.........7 ---------------------------t --------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local health 'strict for a permit to construct and install the work herein described. This application is made in compliance with Cou ty Ordin No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION--- � ---------------- -` .rr- - CENSUS TRACT Owner's Named Phone----------------------------- -------- Address----- ---------------- -- ----------- -- ..----------------------------------City---- ... Zip Contractor's Name-.. --------`------------ - ------------------- ise #_'Qs�s� Phone ---------- ------ Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ "Moue-❑ ther Number of living units:-------_�.-----Number of bedroom -Garb rin t e------ Q_---- --------------------------- ] ` _______Private ❑ Water Supply: Public System and name - -------------------------- Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ I 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 i sewer ' a'Gailable within 200 feet,) r PACKAGE TREATMENT [ ] SEPTIC�p,NK /�A� e-- .___'- _ - ---_ quid Depth._��----_---- 1 1 6W Ca adt e-----------------------Mates'------- �o. Compartments--------------- _--..- Distance to near st II_,._L__e. ------------ Foundation--_-- .r_______-Prop. Line____-_ -- '� , LEACHING LINE rte] No. of Lines__- ------------ _____.Length of each line.__ . _ . -__:__.Total Length_---- ----------- - _::-_--__-- D' Box_---------T a Filter Material.-----. Depth Filter Mat Type ,,. Material.., P Distanceto nearest: Well:-, f > -Foundation.___.- --------.Property Line-___. ------__._---_--. SEEPAGE PIT Depth: ---Diameter.- 3f,__Number---_�____________ __ ______ Rock Filled Yes ❑ No ❑ Water Table Depth-----------------1/-,L--- ------------ Rock Size4�5� � Distance to nearest: Well------ �.--------------Foundation.. op, Line.____..- ---------_.-. REPAIR/ADDITION (Prev. Sanitation Permit#------------_----------------_------.-------.--_.Date.-----_.____._----------_ .---------------.--) Septic Tank (Specify Requirements)---------------- -- - ---------------------- ------- Disposal Field (Specify Requirements)------------ ------ ---- `-----------------------r--------------------------------------------------------------- ------------------------ -- ---------- ---- ----------------------------------------------------- --------------------------------------------------------- -------- ----I------ -------- ------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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. Horne owner or licensed agents signature certifies the following: "I certify that in the perftrmance of the work for which this permit is issued, I shall not employ any person in such manner as to became bje to o kman�s mpensati laws of Ca i ornia." �- ' Signed-------- -- - -- _- .__--__�_---�--kOR o�------.--- ner BY------- -------------- ------------------------------------------- - -- - -------- -----.-Title---------- ------(If other than owneDEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ----- --- -- -- ---- -----------------------------------------------------------------------DATE. '7 X ------------------- DIVISION OF LAND NUMBER ---- - ----- ------- - --- ----------- ------------------------ ---------------- --------------- DATE-- ------------------ - -------- ADDITIONAL COMMENTS--.- ------ -------- _ � _- - ------------------- ----------------- --------------- ----------------- - -- --- --------- ----------------------------------- ---------------------------------- ---------------------- --- ------ ------------------- ` ---------------------------------- ------ Final Inspection by:--------- - - -------------� ---------------------------------------------Date.-� - '�-7.7� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FBS 21677 REV. 7/76 3M