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o i ` `-" 'FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT '� -------------------------------- ---------------- - Permit No.. 7_7_-._?_? (Complete in Triplicate) ------- ---- ----------------------------------- -- a -)- 7 7 Date Issued_. _ __._.____._ -------------------------------------------- ---- - This Permit Expires I 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: �✓' �JOB ADDRESS/LOCATION__= _ ------ - -------------CENSUS --------.CENSUS TRAC - --=- -- /ltA? - ----------- ---------=- Phone-Owner's home ' - ----- -------------------ZAddress. MCity, iP Contractor's Name 5 L N = - --- -------------License #--------------- Phone_. -- - ---_-------------- -- _ s s ._�--. .� ;--....t.- i - � � • installation will,serve: - Residence ❑' Apartment House.❑ Commercial ❑ Trailer Court; ❑ F j s Motel :- _--- - ---- . »»r - ❑ ' : Other__ __ - t F Number of living units _._.__ Nurriber:ofsbedrooms-.___:----Garbage Grmde�r..- -------Lot Size -------------------- _.::_ _________ ________{_._ t , l .: Water Supply: Public System and name ------ ' `r'l --------I- --- - - --- --- -------•-Private ❑ Character of soil to a depth of 3 feet: Sand ❑ S It-0 Clay❑ r Peat ❑ Sandy Loam ❑ ;Clay Loam ❑ F t P ❑ ❑ - - - Material ----•�------If yes, #YPe - - ------------------- (Plot ------------- ---- . Hard an� Adobe " Fill (Plot plan, showing size of lot, location of,system in relation to-wells,1. ild rig, etc. must be placed on reverse side.) . �t NEW INSTALLATION: -'`(No'septic tank or seepage pit permitted if public sewer is available within 200 feet,) # 6 PACKAGE TREATMENT '[']' *'SEPTIC TANK [ ']1' " ' Size-------------------- -- -------------------- ----:-Liquid Depth------------------ (S1 i F 'Capacity- ------------- -- 'TYPe�---=-- ----`---------Ma#erial No' Compartments . ,,.. .. -Distance to nearest: II_ - ------=-------------Foundation_------`-- ------------:Prop. Line-------------------------- LEACHING LINE ['] No. of Lines __ _____ __ _____Length of eoirh,lno l ____ o#al Length----- _ � i t -'D' Box---------".--Type Filter Material __- -- ---____--Dep#hc'FrltelrMater�a--- ------------------- --- - y to nearest: Well_]__: -_Foundation_______.__- _� _.Property Line-------------------------- Distance SEEPAGE PIT [ ] Depth _ __Diameter._ ��- Number___' ____ _ �. Rock Filled Yes Noo oeai F7 L7-5 Water Table'Depth--�0-----------------—- + --------------------Rock Siz --- - ----- - ----- r9 x r30 Distance to nearest: Well----svv_---__ v`__Foundatio ��__._.__.___ Prop. Lme.__�___� -- I REPAIR/ADDITION (Prey.•Sanitation Permit#-------------------------------=-=--=--------------Date_------' ------------- -----) l Septic Tank (Specify Requirements)- i-------------•-------- = --/� f------------------ - i - � = /�---- --- ------------ Disposal Field (Specify Requirements)_.______ -- ----/i--.__` __CJ---- --X---------- '-.-li - --"-1------� - ' ----------------------------------------_ ------------------ -------------- --- h ----------------------- --------------- --------- ------ ` = --- -- -----=-------- -- _:_.. ------------------- ---- (D d d addition�; d ) ,..._ , . .. . , raw existing an require a ion on rev rse si ,x I hereby certify that'll have prepared this 'application-and-that-the-work-will be donla*l�actoo dIbnce with San- Joaquin County Ordinances, State Laws, and Rules and Regulations�s#i ith j Sant aqui Local He tth Dis riot, Home owner or licensed agents signature certifies the following: "1 Certifythat in th performance of°the woracor. whit tis a ntit.�isd I sFial 't-em16 do erson in such manner as P - r y. Y p Ire to become �s�j� to Work stn's �p sation; laws f�California." Signe&4_ c-! Qnert. f e .._.-_.---'---------- --'---------- - BY- ------------ -- - - -- ------------------ ------r �..... _,�. If other than owner) )tt ' FOR DEPARTMENT USE O 111Y APPLICAT101V_ACCEP_LEQ Ba'= = = -= ° oaT�- --....77__7_._ DIVISION OF LAND NUMBER ------=-- '------------------- --------I. ----------------- ------ :------.-- DATE--- - - T . --------- ' - -- ADDITIONAL COMMENTS--------- ---------------------= = :. - -.------ .. = `-- ------ -==--`---- ---- --------------• - ----------- ------------ -------------------- _------- --- ..____s_______________________________________________` __ --------------------------------------------------- -- ___ _______-------.___.__ __ --------------- _ _----- ----- .----------- -- - Final Inspection b - ,. �,. Date- EH ------------- P Y:'�' - ---------------------------- 13 24 SAN JOAQUIN OCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M 0