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FOR OFFICE USE- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------------- --- -- 77 r- P/ (Complete in Triplicate) Permit No._.._...._______--- -•------------------------------------------------------ This Permit Expires 1 Year From Date Issued Date lssued___� 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 Or inance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIOB ---- - l� 'rc: -- - CENSUS TRACT Owner's Phone---------- ------- Address QQ 7 .!/ r g o f.- ._-.. ------ ----- J -----------------------------------City..:---- - - ----------- -- -----Zip-- Contractor's Name--- �r �l ' 't.� License # - -Phone -----------Q Installation will serve: Residence ❑ Apartment House.❑ :Commercial.❑ Trailer Court ❑ ' i Motel ❑ Other = .:: = - Number of living units-------- -------Number of bedrooms------ Grinder.---------.__Lot'.Size_:_=__.__Q t ----- ------------------- Water Supply: Public System and name-.-:,;:------ -- ----------------------------- Private 3 Character of soilto a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat E] Sandy Loam EJ 'Clay Loam Hardpan EJAdobe"[- Fill Material----._-.-.__If yes, type-------------------------------- (Plot ---------------- ----------(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 see age .pit permitted if public sewer is available within 200 feet,) [� PACKAGE TREATMENT ["j' SEPTIC TANK [ "� - Sizer-___ :Q_ -�'_�--------- _______________Liquid Depth ------------------- C apacity.1-1 __---_____._____Capacity./ Materaal. _Z, 4_No.-Compartments---.Z Distance to nearest: Well f�' - r me_____ _-__ Foundation ...1�� -----Prop, L LEACHING LINE [ No. of Lines::---- _- __..,_-.Length of each line_.-.----IV2 �---.--Total Length __:.Lia-/ _________ D' Box-- _ _.__Type Filter MaterialLL----- em_ Depth Filfe�_Ililcaterial.--_f ------------------------------------ Distance,to nearest; Well_=- _l-�'_Ct T ___--.Founda'tion__- _G___.--------- ---Pro erty Line.__-__ � ---- ___ SEEPAGE PIT 'm`f- -- [ Depth.- ---.Diameter--------- �----.Number--`------:---- --------- - - _ Rock Filled .Yes No Water 'Table Depth---- = Rock Size f/ - s ------- -------.Foundation. l `--------:Prop. Line---- i F Distance.to nearest: Well ---___._.--- J -------- REPAIR/ADDITION (Prev. Sanitation Permit#-------- -------------:-_----------:�' ---------:Date.----=----:--.-- .----- ) -- Septic Tank (Specify Requirements) :° P------------ ---------------------------------------------- Disposal Field (Specify.Requirements)-------- --'- -----•-------------------------------------- ------- I----------------- -------------------------- -------------- ------------------------ -------------------------------------------------------- - -------- --------------------- ----- .(Draw existing and required addition on reverse side[ 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, Home owner or licensed agents ) signature certifies the following: "I certify that in the performance of'the work.for which this permit is"issued,':l shall not employ any person in such manneras- to become subject to Workman's Compensation laws of California.'.' Signed--------------------- Owner �-- x By-,------'---- ----- j -- i..- �'--`- a -------- ---- Title-- f=Fac----------------------=-- --- If other than owner} r / i ' FOR�DEPARTMENT USE ONLY f r t APPLICATION ACCEPTED BY------ -r--- -- -- � ----------------------------------- - '' DATE. - �9- `- DIVISION OF LAND NUMBER.----- - DATE - t�- --- ADDITIONAL COMMENTS----- ---- --- -- = = F ------------------------- -- =-- - - ----- ------------------- ------ ------------------- ---------------- ------ _ ----------------•----------------------_--------... __._----.- ."--------------"----"'-----"�---------- ---- - - •. :. a - -------_-•--------_____ Final•Inspec#ion by:. - " ----- -------------- --- Date I�_J. - -:_._ ._Y_ _-______.__._._-- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2fP7 REV. 7/76 3M