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OR OFFE FOR OFFICE USE:. U APPLICATION FORSANITATIONPERMIT 7�-- 76 yDo Complete in Triplicate) Permit No.______�I_______ j I Date Issued________l7_=_�� ...-.._.__-__-__________________________________.-_ 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. V9 and existing Rules and Reg at' ns: JOB ADDRESS/LOCATION.3Q_e---0 - ---- -- ----------- -------- /�-----------CENSUS TRAC Owner's -------- ---------- - ------- pp Owner's Name-- - -70e__ -- ---- -- -------------------------- ---- ---------------- -------------- - ----Phone_P� -�_ _ �;�- Address- �Gr� =- I��--'--- --- ---- ---- CitYl Zip-_9 -� - //�� Contractor's Name__L�-� •.__ '� ___.___-__.___._ License #_ � -Phone___________ Installation will serve: sidence Fil artment House ❑ Commercial ❑ Trailer Court ❑ i. Motel ❑ Other-------------------------------- ------------- -� Number of living units:----------------Number of bedrooms._/------Garbage Grinder____.-------Lot Size______. ___o___ --------------._______-IZ�7 €y Water Supply: Puhc stem and name----------------- -- --—-_ ---- ------- ----- ------- ------ ---------- ----------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt t] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ill 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 seepage44-permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Size-----------------------------------------------------------Liquid Depth_________________________ ------------------.-._---No. Compartments_f . artments _�L__ ------ ----------a Disfance to nearest: Well___:_---------------------------------- _______Foundation--- -----------------Prop. Line_, _________ ----- ,._ LEACHING LINE [ ] Ng, o s>>... ______ ______ ,-,Length of each ina---------------------------.--Total Length . . ____ _ _ _____ `B`''8ox .:__Type Filter Material_A__ ____:-Depth Filter Material_.,`.�� ----------------------------------- Distance ___-___ _ ----- --- - Distance to nearesT':'°'aVeTi_7t,-t__.___ .__.____..Foundation__ ____-____-_____ _ __Property Line--------------------- _ ___________ ? SEEPAGE PIT [ ] Depth_ ___________Diameter_ -_.._Number_.-------------------------- Rock Filled Yes ❑ No F] .Water Table Depth ---------- ---- Rock Size-- --------- ---------------------------------- Distance -- -------- --------------- Distance to nearest: Well---------------------------------------------Foundation--------------------------Prop. Line---_------_.--------------- REPAIR/ADDITION (Prev. Sanitation Permit#___ ______ _ ____ ---------------------------Date---------- ________ ______---_Septic Tank (Specify Requirements)---- } y fL 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 sub'ect to Workman's ompensat'row laws of California." Signed-- --- ------------------------------' --------------------------Owner BY----------- -------------------------------------------------------------------------------------Title-------- --------------------------------- (If other than owner) FOR PA TM NT USE ONLY APPLICATION ACCEPTED BY--------------c------- -- ----------- ------------------------DATE.-------- - - DIVISION OF LAND NUMBER --- ---- - ---------- DATE. ADDITIONAL COMMENTS------------------------------ ------------- -------------------------- ---------------------- ------------------------------------------------------------------ ------------------------------------------------------------------------------------------- ------------------- - ------- ---- ------------------------------------------------ ------------------------------------------------------------------------------------------------ ------ -/- --- --- --- ------- Final Inspection by: ------- Date 1p '—� `� ' _ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 31A