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I � FOR OFFICE USE: FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT Permit No. 77-/O/� ---------------------------- -------------------- (Complete in Triplicate)- 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. I This application is made in compliance with County Ordinance No. 519 and existing Rules and Regulations: �# JOB ADDRESS/LOCATION.,__., .. =E� c� /"'[rllL�__._ C --------------CENS rTRACT----------- ----- _-_------- F . FFOwner's Name.------- " � �SGy/t) ------'------- - ---/Phone. - .- Address - �.�------ G. ------------------------ City _/��.0 dip ? . - .fes �5 ._ Contractor's Name----€ '- -'--��-- --C -------------- A Z _ ------------License #-------- --. ----Phone - =- ` Installation will serve: i �� Residence jy1, Apartment House.❑ Commercial ❑ Trailer Court L] t . units;_ t._.: . . Motel ❑ Other --=-- ---=---- ---=--�- Grind =r--- _ .__..__.__Lot Sizer_. 1 _._ ________________Numberof.living units:. ` ,_.`______Number of bedrooms-. G 'Water 6upply. k Public System and name----------=----------- ..-----------------------------'�-------------------------.-_-.-._.------------------------------------------Privet e Character of soil to a depth of 3 feet:, Sand ❑ Silt ❑ Clay ❑ ' Peat ❑ Sandy Loam Clay LoAm El 'Hardpan..❑ . Adobe E] Fill Material__ .j If yes, type__:-------°_____ --- __ I(Plot plan, showing size of lot, location of.system in relation torwells, buildings, etc. must be placed on reverse side.) : :NEW INSTALLATION: '(No septic tank`or"seepage pit permitted if public sewer is available within 200 feet,) j� p PACKAGE TREATMENT [ ] . SEPTIC TANK ['] ----------------Liquid Depth. ---------------- -----------___.Capacity/i C`_ -- �---- ___:__._No. Compartmentsl _ _ ---- Distance'to nearest: Weli-.fr_4�..)-- ---------------------"Foundation----- -_.____.Prop. Line_��V-�______________� I _ ----- - Length of each line.-20- ---.Total Lenglh1-- LEACHING LINE [ ] No. of Lines-- Type Filter Material Depth Filter Material_.____ ----------------------------------------------� D Box ,,.,-= ,Distance t`o Barest: Well-------- ' Foundation---------- ------.Property L ne-- -------------=------Y______ _ SEEPAGE PIT [ ] Depth ______._Diameter--------------------Number---------- __ ___-____._.___ Rock Filled Yes EJ No❑p Water Table Depth.------- -L-----------------------------------------------Rock Size ------------- ------------------- Distance ------------------ Dstance to nearest: Well-----------------------------1------ -----Foundation---------.------------- Prop, Line.-------------------------- REPAIR- /ADDITIONS(Prev._Sanitation::Perrnifi# Date ] ] Septic Tank (Specify Requirements]:--�------------ --- ----- --------------------------------------.------- -^ ----------------------- -- --- - - ------------------------- . Disposal Field (Specify Requirements __---.---, ---- ----- 3 ------------------I-------------------I------------------ - ----------------- - - -- .:- ----- - - --- ------ ----------------- --- --- ----------------------------------------- ----------- - ---- �: (Draw existing'd�qu,]l.red,additi.on on reverse side] 1 I hereby certify that 1 have prepared ibis application and that theme-work will be done in accordance with San Joaquin County i Ordinances, State Laws and. Rules and Regulations of the�5anlJoaquih Local Health District, Home owner or licensed agents signature certifies the following4- "I terti that in the erformance of the work,for which this er''�'it is issued, I shall not employ any person in such manner as to become subject manCompensation-laws of_Cali 8rhia.' . s e a. }. Signed .. ---:------------ -------------# -Owner ( t � _ Title.BY-------- --- s (R.-ofi er than owner) r FOR-DE-PART•MgNT-UgE ONLY # APPLICATION ACCEPTED BY----- ------------ -----'----- ---- DATE - r -------- OF LAND NUMBER.-------- --- --------------- = : . ...:.. DATE-,--- DIVISION --- --------- ADDITiONAt COMMENTS ---------------------------------------------------- < - ----- ----------- - ------- �_ s -------------------------------------- -------------------------------- `� -- --------------------------- ----------- ------------- ---------------------------------------------------------------------------------- ------------------------------- ' Final Inspection by -------------------------------------- ------------------------------Date---- = �_�._ �� 7_�----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M