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FOR OFFICE USE: FOR dFFICE USE: ?� APPLICATION FOR SANITATION PERMIT ----------------------- ---- Permit No..7_/--.FSF (Complete in Triplicate} - ------------------------------------------------------- Date Issued-0=K_`17 ---------------------------------- _____--- ------------- 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 Re�lSytions: ��f q '7 6 r L. JOB ADDRESS/LOCATION _ ........... -------- ---------CENSUS TR T-------------- ------ Owner's Name---_7p--�" -- - ---- .. ..-- {. --Phone-------- ---- Address----� a C --- -------------- ---------- ---- ------------------------City--------------------------------- ------------Zip------- --- ----------------- Contractor's Name Name----- ---------------------------- License Phone--- Installation will serve: Residence Apartm nt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------- ----------------- Number of living units:..` ---------Number of bedrooms.--,,7-_.Garbage Grinder_ -Lot Size----- __ _ ..--__- . Water Supply: Public System and name--------------------------------------T- ----------------------------------------- '---------------- ----- -------------------Private. Character of soil to a depth of 3 feet: Sand ❑ Silt El Clay E] Peat ❑ Sandy Loam E] Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material- --.-.--.-If 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 within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.... --- ---f— ,X_ ------------- ---------Liuid De th._- Capacity- - Type----,9------------Material-----e--'7-------No. Compartments-------1p,--------------------- Distance to nearest: Well------/Q_-f -------------__---_---Foundation-----/__0_.-----------Prop. Line..../_47-------.-_.__-� LEACHING LINE [ ] No. of Lines.--.--- --------------Length of each lina------ � _ Total Length.---�-- p -- 'D' Box----/-----Type Filter Material---- --- _--Depth Filter Material"- --f ---------------------------------------------� �. DistcLngaJo nearest: Well____ - - ---`-- ----Foundation---,IZ9-----------------Property Line----/0_______-- 9 [ ] Dep i eter ---------Number---------- -------- ---- Rock Filled Ye No ❑Z Water Table Depth---------- Rock Size--------1 ----------------- p Distance to nearest: Well-------.-__.____________________----.---.Foundation--- --.Prop- Line -----__-- 'y REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date.---------------------------------------------] Septic Tank (Specify Requirements)------------------------------------------------------------------- ------ 3 DisposalField (Specify Requirements)------------------- - -------------------------------------------- - ------------------------------------------------------------------------------- ------------------------------- -------------------------------------------------------------------------------------------------- ---- F ------------------------------------------------------- (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 shaTI not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed.--- Owner By---------- - Title. ---- --------------------------------------------------- f of er t an own . I ~" DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------1 _'_ ____ __V--- DATE ----------------------------------------------------------------------- -- -- DIVISION OF LAND NUMBER.-- .-- ---/ �� --------------------- -------DATE ----------------------= -- ADDITIO AL COMMENTS---- -- - -- -- - - ------------------ ---------------------------------------------------------- 1f3 'off e4v-------- 1 -- -- � -- ------- ---- -- - ------- --------------------------------------------- - ---- ------------ - -------------------------------------------------------------------------------------------------------------------------------------- Final Inspection by-------: Date-/6 —X/--i= ------------------ EH 13 24 / WJOAQUIN LOCAL HEALTH DISTRICT FRS 21677 REV. 7/76 3M