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'FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} Permit No.._.7I�._.�-- --------------------------------------------------------- -7�--------------------- ----------------------------------- This Permit Expires 1 Year From bate Issued bate 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION : ; � y-^ - .CENSUS TRACT- Owner's Name----------- n, o_Z----- ---------- --------- --------------------------------------- ----- -----Phoneg��---- Address------------ - -----------5/9l City- e Cf� -- Zi p------------------------- -------------- Contractor ------------------------ Contractor's Name -------- / .1---- �44 � /;�-------------- ------License # � ------Phone.__��"� Installation will serve: Residence ® Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-----w, - AC Number of living units:.--./---_------Number of bedrooms---4�...-.---Garbage Grinder----__------Lot Size.------�--_____~____._--__ __________________ Water Supply: Public System and name --- ------------------------------------------- --------------------------- ----------------------------------- ---- -------------Private [ Character of soil,to a depth of 3 feet: Sand ❑ Silt[❑ Clay ❑ Peat ❑ Sandy Loam X 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,J PACKAGE TREATMENT [ ] SEPTIC TANK w ----.-5i_z_e- "_� ---G- �' - --- -----------.- --Liquid Depth.- -- '--� - j-_/__ ----- - Capacity/ 4 ----- Materia!--------------------------No. Compartments._ ------------------------ Distance _ ._------------------- - Distance.to-nearest: Well--- ------------------Foundation../� i_________________Prop. Line_ - ----------------- �� - LEACHING LINE' No. of Lines___--------- ----.---_Length of eachline_ -- �-- ---------------Total Length..---- ?le � -------------------- 'D' -- ------ -------- D' Box---f..._...Type Filter Materia l_, ,/ Depth Filter Material------- -------------------------------------------- Foundation--nearest: Well- ---------- --------------- SEEPAGE PIT ITE] No E]_ [ 1 :Depth"---------------Diameter.----------------- Number------------------ -_----___ Rock Filled Yes R 4 �,. • 1 Water ,Table Depth `--- - - - - --- Y-- ---------------------- Rock Size = ------ -------------------------- Distance to nearest: Well---_______________________________________Foundation----------i-.____-----..___ Prop. Line._---_-.--------__.________- REPAIR/ADDITION (Prev. Sanitation Permit#�-.--;----------------------------------------- ------------�--------------------------} Septic Tank (Specify __.._Requirements)---- %____ ___`: �_ y ] .f I --------------- -----------------------------------------. --------------------------- Disposal Field (Specify Requirements)____..--.._____----- 1 _4 ... ------------------------- ---------------I--------- ----------------------------------------- -.- (Draw existing'and r66IUred 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 af'the San Joaquin Local Health District, Home owner or licensed agents I signature certifies the following: 7, y "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 t ork n's Compensation laws of California." Signed--- ""� ---------- ----------- ------------- ---Owner By---- -------------- -------------------------------------------------------------------------------------Title------------- ------- -------------------------------------- --------- (If other than owner) FOR DEPAR T USE ONLY APPLICATION ACCEPTED BY----- - ---------------------- DATE. = DIVISIONOF LAND NUMBER--------------------------------------- ---------- ---- ----------------------------L---DATE-- --- -------------------------------------- ADD]TIONAL COMMENTS-------- -- - -------------------------------------- ----------------------------------------------------- -------------------------------------------- ---------------------- ----------- r• , lY.Y. ______________________________ __________________________________________ Final Inspection by .......... Date.-l_" - EH 13 24 S JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M