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FOR OFFICE USE: FOR OFFICE USE: #""APPLICATION FOR SANITATION PERMIT -------------------- ------------------------ (Complete in Triplicate) Permit No.7�6�Q ------ Date Issued.7_-/ --7 ------------------------------__---------- -------- -- 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 herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO -- -- --- -- l:-- g- r- -------- -----------------------CENSUS TRACT--------------------- ---------- Owner's Name ---- --- ---- -- ----------- ----------- ------- ---------- --- -- -- -- ---------Phone------------------------------- ------ Address----------- -- ...1-Z- --- -��------- ------ ---City._ Zip `5 Contractor's Name-------- _-_�. _ �___7License #_ zZ' -L---_Phone_______----- Installation will serve: Residence [L]�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------------------------- Number of living units:_ of bedroomT _Garbage Grin er_______ lot Size.---1. *__ _--.--.��_�_____,.-- ' Water Supply: Public System and name---------7—FRI -----------------;------------- Private ❑ Character of soil to a depth of 3 feet: Sand Clay ❑ Pe n y Loam [Clay Loam ❑ Hardpan ❑ Adobateflbl--.--------If yes, type-------------------------------- {Plot plan, showing size of lot, location of system in re]ation to wells, buildings, etc. must be placed on revea-se side.) NEW INSTALLATION: {Noiseptic..tank or see ge pit permitted if public sewer is available within 200 feet,} 00 PACKAGE TREATMENT [ ] - SEPTIC TANK [7 Size_.___,-----X 1 0 _r_X ---------------Li quid Depth __ ---------_________.-- Capacity.- L0_,V___---:Type - Material---- = -----No. Compartments----------------------- - to nearest: We ----------------Foundation.-----_-r-D--_.________Prop. Line_______--------- LEACHING LI E [ (. Distance No. of Lines.r-._=. :-_--._.-,- ___.Length-of each lins----.- -a_-_ ------------ Total Length------ -��_______________________ D' Box----t------Type filter Material___-S-.k-------Depth Filter Material------_1 -_--_.------------------- C � r i Distance to nearest: Well______-.g-p---. Foundation-------1___p---------------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----------------------------------.----------I 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--------------- ------------- --- --- - -- -------------------Owner _ BY /~� ----.-Title_--- --- -- -- - ------------------------------------- If other than owner OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- - -- ------------ ---------------------- --------------------------DATE _ l 3 f,-/------------------------ DIVISION OF LAND NUMBER-------- --- ----- ---- .1--------------------------------------- DATE ADDITIONALCOMMENTS.---- --- ---- ------------------------------------------------- ----------------------------------------------------- ---------- ------------------------- -------------- --------------------------------------- ---------------------------- ----------------------------------------------------------------------------- ------------------- -------- ------------------- - ------------------------------------------ ------- ----------- --- - ------------------------------------------------- Final Inspection b ` --.Date.._. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &S 21677 REV. 7/76 3M