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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT' / ------ r (Complete in Triplicate) Permit No.-..._7_ - fZ1 - -------------------- �,^�•.�, Date Issued.-/ ..............7 .:...-------------- 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: JOB ADDRESS/LOCATIO Y ------ - --------------- SUS TRACT--.---.----------- ---.- n /► /- / 7 Owner's Name---- --- / �GLc.QG'-P�t�J. -17 T't� C/t �Ct/ P.!/' Phone */,, -- ---- ----- Address- --- ---- -- --- --- -IR- --- - - - -------- ---- -w.,----. City---- -- ----- ---- -Zi Contractor's Name--------------- .-----.------------------License # --Y --------Phone 6_ -------- -- Installation ----- --- Installation will serve: ResidenceApartment House.❑ ,,Commercial F-1Trailer Court Itel ❑ Other------------ --------------- ---------------- Number of living units:-----(-------__Number of bedrooms...-.------- Grinder-------.....Lot Size.......... 2- -+a. ,—---------------------- f. Water Supply: Public System and name------------------------------------------------------ ------- ------- ----------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material------------If yes, type--=----------------------------- (Plot ---------------- --------(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 sewer it-available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK Size__ _r-rte___ _- ------ --------------------Liquid Depth._:--------------- �..__.. Capacityll W -----Type `G!' ----- Material No. Compartments-------- -----------------------1�/ Distance to nearest: Well__. Q---t-------------------_-Foundation,___/.d_...._._.-_..Prop. Line. I-t-`..__..----- -_. LEACHING LINE ] No. of Lines-------2 _____________ Length of each line _.. ...............Total Length ___/ _f ---------------....... 'D' Box------------Type Filter Material-- -_ _- -----Depth Filter-Material--= r 8---------------1--=-----------------,.--_ Distant&to nearest: Well----- 0--_f'"___.____.Foundation s_---�_Q--- -._ Property Line.-.S..f"---------------- SEEPAGE PIT pC] Depth...Zc�------Diameter. H_- Number--------�------------------ Rock Filled Yes No vv If Water Table Depth----------- ----------------------------------------Rock Size__3 �rZ------------------------ l � r Distance to nearest: Well. ...........................Foundation_-__.1.Q__k--__._.-..Prop. Line...-5--_�._.-..-.---- REPAIR/ADDITION.(Prev-. Sanitation Permit#---------------------------------------------------Date-.-._.--.._-...--.-_--.--..--.-.-._-------_) Septic Tank (Specify Requirements)------------ ------ --------- --------------------------------------------- ------------------------------------------- Disposal Field (Specify Requirements)----------------- ---------------------------------------------------------------------------------------. ------------------------------ -------I------------------------------------------------------------------------------------------------------------------------------------------------ - -------- ------------- (Draw existing and required addition on reverse side) , hereby certify that I have prepared this application and that the work will 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: "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--- -------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY fi l� 7 APPLICATION ACCEPTED BY..............._-..___ . ---.DATE ___----..__-...__....- DIVISION OF LAND NUMBER -- DATE------------------------------------------------ --- COMMENTS.f. � 7--.----�-�5c_.-�' " � ---------- ��-�-o--------- ----------------- U ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ----------------------- --^ - - --- - - --------------Date �� S J 77 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M