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,AOR OFFICE USE; APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No.._.�_.�-"�________ ------- --- --- ------------------- � Date Issued___i__[—___________77 •---------------------------------------------------""--- , "'-''`This Pe'Ym1t•l9xpires-i Yeibk Frond--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� a 1!_f}�' `-'o�"`�-- ----------------------------------------.CENSUS TRACT---------------------------- Owner's Name.-- . -- ----- ---- -- . 1 -071 ff _Phone__ _ _ Address. �. A - �--- Crty Zip - 9V-1.4 `` Contractor's Name-- - --- -- ----- -•-- - -----------------License # 3 -------Phone__ + -�60�-------- Installation will serve: Residence N( Apartment House ❑ Cornrhercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------------------------- Number of living units:____----------Number of bedrooms------3---Garbage Grindex`_----------Lot Size.__._,_„ --______________________________ { Water Supply: Public System and name------ ----------------------------------------- ------------------------------------------------------------------------- = -,Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay L-oain ❑; r - Hardpan ❑ Adobe r� Fill Material.- ----- --lf-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 sewer is available withim200 feet,) -" :-�,> / r % i/ PACKAGE TREATMENT [ ] SEPTIC TANK Size,-----�-_�_�---__-----__________________________Liquid,Depth:_:5�._±._.-_._ Capacity_ . _ TCompartmentsA �~' ------ YPe -�---- -------------Mdter.ial--- �---'--No. -=----- �--------- --Sl Distance-to nearest: Well.". _ _______ ______ -__._Found�tion_.lJ�_ '__'_�.____Pro Linet�_ _ V✓ LEACHING L1NE ] No. of Lines---------- ------------Length ''f eaAAch Iine.__ r Total Length _ _____-.________ ` 'D' Box-_-_t Type Filter Material___�6L___.Depth Fi ter Material______��-------------__________�________--------------- N Distance to nearest: WeIL.__�Q__I_1- Foundation_____�Q_g_'f-____!____Property'Line- _sz_47------------------- SEEPAGE PIT ] Depth.__.__)S_, -------Number-------------------------------- Rock Filled Yes No OZ Water Table Depth---------------------------------------------------------Rock Size- -6 Distance to nearest; Well---------(Cm__ -----------------Foundation--------l0__ _____.Prop. Line-_s, --_______------ REPAIR/ADDITION (Prev. Sanitation Permit# ---------------------------------------Date----------------------------------------------) SepticTank (Specify Requirements)---------------------------------------------------- ----------------------------------------------------------- ------------------------------------------- Disposal Field (Slecify�Requirements) _. --- ---- ----------- -- =-------------- --------------------------- ------------------------------------------- ------------ --------------------:-------------------------- ----------------------------------------------------------•------------------------------------------------------------------------------------------------- ------------------------------ ------------------------------------------------ (Draw 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 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--------- - ------------ ---- -----c---- -- --------------------------- -----�-�------ Owner -------- ---- By__________ ---------------- Title ------------ ------- - ------- ----- ---- ---- (If other than owner) FOR DEPARTMENT USE ONLY --------------- APPLICATION ACCEPTED BY- -- -------- '---------------------`--------------------------- ----- ------------DATE ------ DIVISION ----DIVISION OF LAND NUMBER /Z? ----- --- -----DATE ----- -- --- ----------------------------------- ADDITIONAL COMMENTS f� 7f - "' `- -------------------------------- ---------------------------------. ------- ------ ----------------------•--------------- - -- ---- ----------- Final -- ----------- Final Inspection by:--------------- ----- ------------ --------------------------- -------------------------------- --------- ---pate l-J_11k14 7 ---- FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M