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FOR OFFICE USE: C��/, FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT W� -------------------------------- --- ---- (Complete in Triplicate) Permit No.__.____7$7 __>51SIS ------------------------------------------ Date Issued___7_- .. .-.Z ------------------------------------ -- This Permit Expires 1 Year From Date Issued Appplication,is hereby made to;the San Joaquin Local Health District for a permit to construct and install the work herein described. ` Thi' ',dpplicdtion;is:made:'n'cortipliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION^ V- �J- --------- --- ---CENSUS TRACT.------------------------------- e d Owner's-:Name:.` ----- --------= - ---- .------------------ ---- ---- --------------Phone ` ----- Address - '------- - -* it g C Zip Contractor's Name-- = !----'----- --- -----------License #yo4 �5.Q� Phone_- - f--� :--�--�„ ��,.... -�---�-- .- _ Installation will serve: Residencele Apartment House.E] Commercial ❑ Trailer Court ❑� j I E] Other----'-- ------'-=-=- '-------='--------=----- Number of.Iiving units:_ of bedrooms__._:,-.Gdrba.ge Gr..inder '_ Lot.Size_.,1>J__/�_�_ _ _. ____r___________________ ° Number Water Supply: Public Sysfem,and name------------------ ------- ---- -K -------------- _ _-_. ,__,__Private` Character of soil to a depthofSleet: Sand N_,SySil!_LJ a Q�aal❑ Peat,E] t Sandy Loam ❑ Clay Loam � 4 rHardpan ❑ , Y YP -- -- k (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. Fraustsbe'placed on reverse.side.) Q NEW INSTALLATION: (No'septic tank :or seepage 'pit permitted if public sewer-is a-vaildble within 200 feet,) N 'E ',PACKAGE TREATMENT [ ] SEPTIC TANK [ ] 1 t Siz-e------------- "___----------- --------- _ ---'--------Liquid Depth- -- -------_-- --- Capacity__ -b.d--=----TyP:a.,.=-- --= ---=-- - -.Material_. - - ----- - No. Compartments--- - - � ------------------- K ---- ____--- ---------------------- Foundation---- --.._ _ -- _---Prop. Line_ -------------- k Distance to.nearest: Well LEACHING-LINE _. _ No. of Lines-:_ ______________ __Length of each line ------------------____.; _;_Total'Length _---_-- [J-1-Nd. 1 ' 'D' Box-- -- -----Type Filter Material'=----------------Depth Filter Material_.--1___F_______..________..'_-____ ------------------__-'-- i l 7 Distance to nearest: Well__ ---------------Foundation:---- -_0---_= `____.;_.Property Line- ,--.- - - ------------------ SEEPAGE PIT [ ,] bepth:__. _._.__'_.__Diameter______________;____.Number____.__.__ ------ ------------- ' Rock Filled ;Yes ❑ No ❑ Water TablelDe th.---.------- -.._------ . . . Distance to nlearest: Well - +=--------------------------------Rock Size -------------------------------------------- Distance - -------- -------------------- - P f _ + ------Foundation - --- --------]----Prop. Line-'------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------------------------------Date----- T- -----------------------:-------- - -} Septic Tank (Specify Requirements)-_.-'- __________ _____ ____ - l ---- ----- Disposal field (Specify Re -�_ - ------------- i 6cf�eisfing and required addition'on reverse side) I 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 1 signature certifies the following: 1 "I certify that in the performance of 4he work for which Ythis permit is issued, 1 shall not employ any person in such manner as to become ject o orkman' ompensation laws of California." Signed--- -----------------=------------------- -------Ownar By--------=------'------------------------------------------------'------- --------------------Title----------- ------------------- ----------------- - --- ------------ (If other than owner[ FOR DEPARTMENT USE ONLY APPLICATION AC-CEPTED-BY=--=, :r: =--- - -- ------------------------ _ " " _ DATE._. .` .-—`j 777' -----+._._ DIVISION OF LAND NUMBER._ -------------- --------------------- ----- DATE. -- ----------------------------- ADDITIONAL COMMENTS' --------------=--------------------------------------------------- ------------ ------------------------------------- ---- ------------ # _____________________________________________________________ ----- -------------- --- -- -- - ------- - ----------- ----------- = = >e Final Inspection by:------- --------=- - - -- --- -- --- -------- -----=--=------------------::---=-------------_----__-------------Date -------- ------------ EH 13 24 \til SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 2_167 REV. 7176 3M 1