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FOR OFFICE USE: FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT Y-ft l-*�►-r fa Permit No------- -- --- -- ---- {Complete in Triplicate) -- c Date Issued___.Q-�� 77 - - -------------------------------------- - This Permit Expires 1 Year From 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 Ordinance No. 549 aan existing Rules and Regulations: ----..CENSUS TRACT--------------------------'--- a OB ADDRESS/LOCATIO _. . - ---------- ---- ---- - -------------------- J S Owner's Name._-------- '� " _ - - ---- -- -- --- ------- owner's II r -- -------- City--e - - = Address--------------------- �+�� y-C- - --..."...----- ---- ----- �e � 7 sZip Contractor's Name --- IV.. -- ----- cense # ._ Phone: Installation will serve: Residence Apartment House.❑ Commercial El Trailer Court El F Motel ❑ - Other- --------=-------------'--------------- --- ' Number of living units:-------------Numberof be'droo' ms------ Grinder--------- -Lot Size--------_.____.___- .__. . =1= ---------- --------Private Chaa�aeter of sol tol'a depth of 3dfeetme d ❑ n Silt �.:�- -----------------------------------.----------------- :---------�- . PP Y: . _y.. m an -- - i p ❑ Clay-❑4 Peat ❑ Sandy Loam ❑ .:Clay.Loam ❑ j �'. y e--------- Hardpan ❑ Adobe ' Fill Material_-.._____. _!f es, type (Plot plan, showing size of lot, location of system in relation to wel[s,vbuildin,gs,etc.must-be.pl.aced.on reverse side.) NEW INSTALLATION: (No septic tank" o'r seepage pit permitted if public sewer is available within 200 feet,). SEPTIC TANK [ .] Siie-----`--- - . ` ; '{ ---Liquid'#Depth - ------------------ - PACKAGE TREATMENT [ ] i' r ` S is s Capacity_ --: ' Type = Material-�=+Foundation.= Pro tmen # p , Line-------------- ------------ p F o. om ar ..Distance to nearest: Well=.__.__-- ----;------0---" ------- r - LEACHING LINE [.l . No. of Lines----------------------- ---- -------------- ----`".Length of,each line,_:------------- t, --:Tota! Length.-----_--------- D' Box_.'____- ___T e Filter Material_r_______-_._'----.Depth Filter Material-.---------- ---- -- ' # rt k - i Distonceto nearest: Well ____-t Foundation_ Property :me ._ _.- -------------------------. SEEPAGE PIT [ l Depth.--- ------Diameter_ " Number Rock Filled Yes ❑ No ❑ i -:----.Rock Size-------------------------- -------- ------------- ! t • Water Table Depth-------------- -------- - -------------- - ; + ! -------- ----= ----I i Foundation._ Prop. Line.. to -i mit# _. . -------------------------- REPAIR/ADDITION (Prev. Sanitationrest: Well.:.= Disfiance -------- -- •�- 5e tic Tank (Specify Requirements)- - µ_ --�-_- ------- � 1 . p Y q r (`""--- � Disposal Field (Specify Requirements)__.,_ -- - �-- �„F� ---------- i ________________________ ______ ___ ______---_._______--._____ ___________._________________. _______-_____._____.____________..____ ___ F _________________________________ � .. ------------------------------------------------ work-willl l Tfie—'done !n-accordance. � ''.(Draw existing.and required addition on reverse side) i - - - .. - . q -- I hereby certify that I have prepared- application and that the 'ordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or license agents signature certifies the following: ; 'Fl 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__-------- `--. r O . ---------- --- - -- --------- Tit'e--- - - - ------------ ------ f her than owner) ! f FOR DEPARTMENT USE ONLY DATE._. - ------------------ APPLICATION ACCEPTED BY ------------------------------ DIVISION OF LAND NUMBE -- ------------ ---------- -- ---- -- -- --- ------------------------------------ DATE = --- ADDITIONALCOMMENTS-- ------ --------- ---------- ------------------------------------------------------------------ ------------- --------------------- 11€ ---------------------------------------------------- t----------------- --- -- -------------------- -------- Y" '_ ------- - ------- -- ----------------------------- -------------------------------------------------------------- ------- ----------- Data ------- Final Inspection by --'"" = -`------- --------- -------- ------- Fas 21677 V 76 3M EH 13 24 /'� SAZ JOAQUIN LOCAL HEALTH DISTRICT