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FOR OFFICE USE: FOR OFFICE USE: . � -�i , APPLICATION FOR SANITAT.ION�P.ERMI � (Complete in Triplicate) Permit No..77-JW... --------- --------- 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 andinstall the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and.R'egulations: ` JOB ADDRESS/LOCATION........ .. ... I �- ------ � ---- ------ - --- -- ----- ....CENSUS TRACT---------- _----------- ame : Owner's Name -------------- --- :: Phone..� _ � - Address------------ --- � _E-- - C '' 1ty - r • Zip. . ; Contractors Name--------- ----- --- ----— License #_ 7., -`f __ ...Phone:.. 6fo ------- 4. Installation will serve: Residence's Apartment House ❑ Commer dl ❑ Trailer Court ❑ f Motel ❑ Other --- - ----- - ` i - ----- ---- Number of living units: Number_ofrbedrooms:-- arbage Grinder._-_ _ LotrSize__.7U.r.. /yU Water Supply: Public System and name. --------- -- -- ;------- ----- _ '.' - ---------------------------•------- --Private Elr I Character of soil to a depth of 3 feet; Sand ❑ .Silt ❑ Clay ❑ {'Peat Loam ❑! Clay Loam ❑ I Hardpan Q Adobe Fill Material_. -----:..!.'-If y type. ................... � es, ---- -- -- � t (Plot plan, showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.) NEW INSTALLATION: ;(Noi'septic tpnk or seepage pit permitted if public sewer is available within 200 feet,) ' PACKAGE TREATMENT ' J- "SEPTIC TANK ....................... -----Liquid Depth -------------------------- t Ca acit Type.-- ------------- ----Ma,terial--------------- ----- --- -No. Compartments------------------------- Distance to nearest: Well-------:_.,_:= ._ `-..— Foundation---�-------------Prop. Line..........---------= 6 LEACHING LINE [ } No. Iof Lines--------------------- ..Length,of each line._,: '____-.'Total Length.--.-.--- --------------------------- 00 'D' Box-..__.-___.Type Filter Material____- _.-__ _'---Depth Filter Materiae..•__,_-_.._-- I Distance to nearest: Well..-------. Foundation----y---_` 7+. 'Line---..J - = r .Prepe -------------- ty SEEPAGE PIT p _=_.__Number...:............................ \ Rock Pil ed.'Yes ❑ No I 1 De th----= -------=-- Diameter-_---•- -.---- __ -�------=�---�-----F r -------- - s. - - -- ---- Foundatio�l - P Line Water Table Depth .__. ___.._ Rock Size _ -_--- _ Distance to nearest: Well _ �- -�" '� 3 REPAIR/ADDITION (Prev, Sanitation Permit#--------------- ----- .--=-f.-_-.-- --Date------,------------ --------`----------------- Septic - -----Septic Tank .(Specify Requirements)____-_ ----- =- ------ ------------------- -------------------- ------=-----=-=--=-- = = - .. - Disposal Field (Specify RequireY". ------------------------------ --------------------=---------------- -- s. -- ------------ ------ ----- ------ - -------------------------------- `- ------------------------- ---,---:-- ------ ------:---- -- ;-------- -=----- -------------- ---------- (Draw existing and required addition on reverse side),-�-�---' I I hereby certify that I have prepared Ais•application and that the work rWill 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: lig "I certify that in the performance of,ihework 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," = Signe! d �,------- :�----------- ------------- - -------�---- --------,OWner BY--- ------------ -= `----- --- --------- ------------- -- Title. ` Title.---- =-----------;--- f f thea than owner)"' 1 i 0)11 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY kz ; - ----------------------------------- -,. DIVISION OF LAND NUMBER ---------------- ----- - ------------:-- -------------------------- ---------------------------------DATE--------•---------- - - ADDITIONALCOMMENTS- ----- ------------------'--------------------------------------------------------<----------------------------------------------------------------------- ------------ --- --- - -- --------------------------------- --------- --------- ---------------=----- -- -- ------------------------------------------------------ -------- ----------------------------- ------------------------------------- ----- r------ --- - ------ --------------- ---------------- ----------------------------------------- --- - - - - -- -- ------------------ Final Inspection by-------- =-- - ---- ---- - --�.--'_,..'r`----- ------ - --- -- ------Date'-`----1- -- ----`" - ----"------- EH 13 24 - .S JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M