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FOR OFFICE USE: FOR OFFICE USE: L.. APPLICATION FOR SANITATION PERMIT = -----.------ `�`� `� (Complete in Triplicate) Permit No... ._. __"_. _3.� ............. ................................. N ..................... ............ .------------------ This Permit Expires 1 Year From Date Issued Date Issuedw5.1:,:'a3.-77 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/LOCATION..... - .. �-- --__.... '------ ------------------------ -------..._.CENSUS TRACT.---- ................... Owner's Name . - -- %lbe .--- .. - Phone_ ` '" 5�"? .. Address._ !1�� City- .... _ •------- -----------ziP Contractor's Name................... .....C - ---- ---_- �- -- _ _-- _ .License #_.��:3-��l_.. .Phone...l.... .. .� ...... ' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_..- --------------------- Number of living units:------ .._-_-Number of bedrooms---s ....G rbage Grinder....--------Lot Size_-Co.d. _- - .............. ........... .. 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 ❑ AdobeW Fill Material....... _...If yes, type................................ i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Gj NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ 1 SEPTIC TANK ( ] Size'_-.- ---- ----------------------------.----------------- Liquid Depth.:--'-•--------- Capacity -•- -Capacity................. .. Type.......................Material-------- ------ .......---No. Compartments_.......:._-.......- _-----------`[ Distance to nearest: Well..................... .. ..................Foundation....-....-.- .---.-..-.---Prop. Line........................... LEACHING LINE [ ] No. of Lines .. .. ......................Length of each ling....-----------------. __ Total Length { D' Box--..........Type Filter Material.---- - ...Depth Filter Material..-----.------------------..................----------........CL_ 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#--.-jQ._�.d__'?..............-------------Date-----3"27-. --,Jl---.--_--..-- -] F Septic Tank (Specify Requirements)------------------- --- ..y . .._..-_._ ... :_._.. 000 Disposal Field (Specify Requirements[.... __. 4/ .. ' - - ..------....1 e ------- ------------ _.....---- -------------- ------- ----- (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 t 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 rk n's pens tion laws of California." Signed. ----------- --/. i- � / t ...------....----Owner 3 By--------- `4/- _`. Title --- ._. k (If other than owner i DEYARTME T LIE 1PNLY f A _Sr DATE ...�__''. .J`_ ...... APPLICATION ACCEPTED BY- DIVISION ._ . DIVISION OF LAND NUMBER.../.-.- ---.-.-.-....... ---------.---.DATE_.................... -,- ---_.- J ADDITIONAL COMMENTS....... - -------- - --- --------------------------- --------------------------------- ------- ..----. --- .-- -.-. ------------------------ ......---_-__._....._ ------------------------------------.-.-...-------- --.._...................... ---------- `- a ; -------------------------------•--------- Final lnspecslon b _,_ ° - Y' -- --- - •---•--------------D ---------- -•-- .. •----.....--- - - ---��-------------- -- ate 3 7 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M