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FOR OFFICE USE: FOR OFFICE,USE: .� AIPPLICATION FOR SANITATION PERMIT 4 ~~_.. 'A 77~� (Complete` in Triplicate) Permit No----------------------- •----- ---------- ----- - Date Issued_ ---�---------�------------- 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. 549 an_ . xisting R les bnd Regulations: JOB ADDRESS/LOCATION.-. . '-.______-__.CENSUS TRACT------ ____._-_ - - Owner's Name...--- o --- - -- --------------- Ph ne----- Address +Cit Contractor's Name__-------- _ .License # KIN------ Installation will serve: *esidence ❑ Apartment House Commercial Trailer ❑ ❑ Court ❑ t Mote! ❑ Other----------- ------------- ---------- Number ------ -Number of living units------- ________Number of bedrooms._�_-_--Garbage Grinde ----------__Lot Size------- �---------------�-__---- Water Supply: Public System and name---------------------------------------- •• P + e s - = = =-- ------- - .----- ----- Private Character of soil to a depth of 3 feet: Sand ❑ Silt[:] Clay ❑ Peaty❑ Sand, ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material----_-------lf yes, type------ ----- --- --------------- �. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse.sid' NEW INSTALLATION: (No sept c tank or seepage pit permitted if public sewer is available within 200 feet;} w. PACKAGE TREATMENT SEPTIC N�K_.—1 — _S.ze. - - --- 4. ------------------- ----- ------------ -_____Liquid Depth------- ----------------- Capacity--- _____________Capacity--- ----- ----------TYPe-----------------------Material--------------------------No. Compartments_?:•-' 1 Distance to nearest: Well------=------------------------------- ----Foundation----------------- --------Prop. Line----------- ----- ----- LEACHING LINE [ I No. of Lines-.__'--- ------------------Length of each line.--------fpk -------------Total Length.__" -- D' Box--- ------- Type Filter Material--------------------Depth Filter Material------------------- ------------------------- Distance to ne'trrest: Well. J ----------------Foundation----------------------------Property Line--------------------------------- PITS.t _ E .l De th,-, � _ -----------Number----------- -- --__ ---- Rock Filled Yes {� No p Diameter �� ✓-} I Water Table Depth ------------------------------------Rock Size ------------------------------ Distance to nearest: Well-------------------------------------------Foundation------------------.--- --.Prop, Line---------------- - --------- REPAIR/ADDITION (Prev. Sanitation-Permitl#--------------_____.___._ - -------Date-------_----_-________-._ 1 Septic Tank (Specify Requirementsl_____________ _______ ----------------------------------------------------------- ------------------------------------------------- Disposa! Field (Specify Requirements)--------- .__--____ _ __________ -- ------------------------------------------ ---------------------------------- N r t - ----- --------------------------------------------------------------- _. �'� - .____-._y (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 Son 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:')' j s , "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 subject to Workman's Compensation laws of California." Signed - - ----------- - Owner BY Title -7 --- -- -------- f other than 'owner] FOR DEPARTMENT LIS9 ONLY APPLICATION ACCEPTED BY-____ ---- ---------- --------- --------------------DATE.. -----�----- DIVISION OF LAND NUMBER. -----------DATE. --------------------------------------------------------- ------------- ADDITIONAL COMMENTS---------------------------------------------------- ------------------------------------------------ ---------------------- - -------------------------------- ----------------------------------------------- ------------------------------------------- ----------- --- ---------------------------------------------------------------------------------- -------------- -- --------- ------ Final Inspection by:________"- ..___ Date_._ -11_ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M