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FOR OFFICE USE. V FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r 6 Permit No. --7a--- ------------------- (Complete in Triplicate) - ---------------------------------------------- Date Issued..,2- 7-7f .................. --------------------- ----------------------------------- 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 and existing Rules and Regulations: z S L� /�+l iri R-�I�-. C CENSUS TRACT---------------- JOB ADDRESS/LOCATION------- — ------------------------------------------------------ ------ / Owner's Name Gt GI'-� DI/A — -----------Phone_.t9f.3&-. .7----9J_ _ ----- ----------------- Address t lr----------ZS-3.Z S----C.oGV,.�-T1C�.Is�--------- ----City -----?�- -- -------------------- ---Zip---Z�^ ---------------- Contractor's - -----�C- � { 1 Contractors Name--- t`{�� D N N s --------------------------------------------------License License #-- 1147' ------Phone�--- -"--31 Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----- ------------------- ------------------- Number - ---------------Number of living units------------------Number of bedrooms-----.------Garbage Grinder------------Lot Size-------- _. Water Supply: Public System and name------------------ ---- ---------------------------------- --------- ----------------------- --------Private ❑ E Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material------------ 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 sewir is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK TA.ze----- a -__-Liquid Depth__________________________" �j �-- ------------ . Capacity------(.;4 -_- Type N Cy Material G NC No. Compartments-------------------------1-------- Distance to nearest: Well-------------------------------------------Foundation--- -- a------------Prop. Line._-- __-= --- Z4 LEACHING LINE No, of Lines_____-__ �_____j---.Total Len 1D� ------------ Length of each line__-.-_� gth ____$6_ 'D' Box-----r-----Type Filter Material--------------------Depth Filter Material---------------------------------------------------------- -- -Om . P51Distance�to nearest: Well__-_:_-- —--------------Foundation----------------------------Property Line-----------------------------------. SEEPAGE PIT V0 Depth. .____---Diameter__--.--.J'..___.".Number-------------------------------- Rock Filled Yes ❑ No ❑ iJ IX f 7,,W,--ter T le,Depth- --------- --- �------------------Rock Size------------------------------------------------ �7 DiistancCe to nearest: Well----------- ------------------- -----------.Foundation--=----------------------.Prop. Line.------------------- ------ REPAIR/ADDITION ----REPAIR/ADDITION (Prev. Sanitation Permit#---.---__`•--------"-------------------------------Date_____..__________-----_--.---.__-__-____----) Septic Tank (Specify Requirements)------- -------- --- --- ^--------- V ---------- Disposal Field (Specify Requirements) ------- --- - .� ------------------------------------------------------ --------------- -------- --- -- -------------- ------------------------- ------- • f --- ------- -- - N ----------------------- -------------------------- ------------- :rI f '----- jDraw 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 Law's, wand Rules -and Regulations of the San Joaquin Local Health District, Home owner or licensed agents I signature certifies the following: "I certify that in the pei'f0 mance..of-the wdrVfor-which this permit is issued,'I shall not employ any person in such manner as to becom subjeck to man's Compensation laws of California." ----.-.Owner r" Signed ---- - ---- --- -- .. ' .= By------- -------- ------------------------------------------------------------------ --------Title-'=,_ . (If other than owner) R DEPARTMEN USE ONLY. APPLICATION ACCEPTED BY------ ----- --f------------------------DATE "- T &--------- DIVISION OF LAND NUMBER------ --- ----- -----------------DATE------ ------ -------- - -- ADDITIONAL COMMENTS---------- ---------------- ------------------------- --------------------- -------------------- --------- ------ ------------------------------------------------------------------------------------------------- ------------------------------ ------------------ ---------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- - -------------- ------ � r - Final Inspection by:------ __-- ---------------------------------------------------------t /'�� -- -- -- ---------------------------- - Date.----- -- � - i 1 Eli 13 2a � SAN JOAQU N LOCAL HEALTH DISTRICT 677 REV. 7/76 3M i•