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FOR OFFICE USE: M- 11414 FOR OFFICE USE: T APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No..._�7�. �3 /i X --77 Date Issue ____________ This Permit Expires 1 Year From Date Issued f Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst-GII the work herein described. This application ' e,4pj.WnpIjonce with County Ordinance No. 549 and exi ing Rules and Regulations: LL JOB ADDRESS/ O TI N/ . ------- - ----- --- - -----------------------------CENSUS TRACT --- -------------- Owner's Name-------- --- Phone ---- -------------------------------- Address--------- r, - -- - ------------Ci ------------------------Zi Contractor's Name.------ ---_ -Al, - . -- -------------------------License #- Q- ----Phone---- -- - --�/�7--� Installation will serve: Residence ❑ Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- --------------- ------------ Number -- -----Number of living units:-----j_--------Number of bedrooms.�'�'_-----Garbage Grinder------------Lot Size -/ --- ---- -6 ........... Water Supply: Public System and name----------------- ---------------I---------------------- --------- ------------------------------------------------------------------Private4 Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan_❑._.,.Adobe-Q—Fi.11-Ma.terial-..- ----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 public sewer is available within 200 feet,) PACKAGE TREATMENT ac t SEPTIC TANA/ K. [ ] Size___ __ � _ __ _0____________________Liquid Depth.__.._ P y� 07 Ca ( .'! ---TYPe-----4---- ---- --Material------ce_,;�/------No. Compartments-------�-------------------- Distance to nearest: Well__.ic.-__=_________________ -__Foundation--------------------------Prop. Line---------------------------- LEACHING LINE [ ] No, of Lines-_?1A,—_- Length of each line.------- '_5 _________Total Length.---11.7-0----------------------- 'D' Box------ Filter Material-__--- /,�(--Depth Filter Material_____f_ _-_--------- ^ Distance to nearest: Well-----/10Tl----------Fou ndation,,,, [ ) Depth._' -_ .,�r Diameter... _ ___________________ , Rock Filled Yes* No ❑� SEEPAGE PIT -_b Water Table be th__________________________ P ------;-------- .I- ------ --I Distance to nearest: Well------------___F/ ------.Foundation.______-._____;----------Prop. Line---------------------------- � k 'REPAIR/ADDITION (Prev. Sanitation Permit#_.________________________ L_-__----__-_____.Date.__.___.___________,_ -----------------f--- Septic Tank (Specify Requirements)-------------------------------- ------=------- ---- --------- --------------- .+ u .bisposal Field (Specify Requirements)---------------------- ------- ----f--- ------------------------------------ -------------------- _-------------------------------------------------------- ------------------- -------- ---------------------------- (Dra 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 iegulations of, the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify.that iii-the performance of the work for which this permit is issued, I shall not employ any person in such manner as ~ to become subjeit to Workman's Compensation laws of California." Signed----- Owner : BY ------------------------------ -Title---------- -, - -� (If other than owner) , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - --------- ----------------------------- ----- --------------------=- -'DATE.------ -�---- DIVISION OF LAND NUMBE --- --- ----__DATE------------- ------ ADDITIONAL COMMENTS------ --- ------- ---------------------------------------------------------- ----------------------- ---- --- ------------------------------- ------------------------------- - ---------------------------------------------------------------- ----- --- ------------------------------------------------------------- ----------------- -------------------------- ------- --- --- -- ----------------------------------------------------------------------------- ------------------------------------------------------------------------- ----------------------------------- -- - ------------------------------- --------------- --- --------------------------------------- Final Inspection by:_.. -1q_, ---- ------------Da#e- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M