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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No..__77_' (Complete in Triplicate) ------------------ ________________ This Permit Expires 1 Year From Date Issued 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, unty Ordinance No. 549 and existing Rules and Regulations: JOB LOCATIQJ - --------------- ° '' ''f.CENSUS TRACT ------ } -� ,ter ` ! Xd` #. f Phone 'Owner's Name----------- ------------------ a Address---- ------------ _-zipd .` T Contractor's Name._ .__t �► d _ _ �-, -----Phone ____License -.-. -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other --------------- - - - _----- #- _-_ u'nber of bedrooms._ _'`Garbage Grind Lot Size____-- Number of living units: . N ,�' Water Supply: Public System and a-- - ---- ----- ----------------------- itt" trG, El- --------------------------- -----------Private Character of soil to a depth of 3 ❑ Silt❑ Clay ❑ Pe ❑ Sandy Loam ❑ Clay Loam J Hardpan ] Ado e Fill Material------------ f yes, type_________ _ ________ __ ___... `a (Plot plan, showing size of lot, location of system in retation 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_____ ________ _�__--__.----___-_ :_----__-----------Liquid Depth._•_ _ ________ _________`-� Capaci�----- ,--------------Type----------------------Material--------------------------No. Compartments----------------------------------Z Distance to nearest: Well-__,___----__-__-_ ___ Foundation_ ____.------------------Prop. Line---------------__ --_ -_-. F LEACHING LINE No. of Lines-------------------------------Len of each line._ _________ __.Total Length---------------------------------------- 'D' _.___ __ _ ----- -- ------'D' Box------------Type il#e+ / at�-------------------Depth Filter Material--------------------------------------------------------------- Distance to nearest: Well----------------------------Foundation-------------------------`---Property. Line-------------_________-__---__-_- SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth----------- -----------=--------------------------- ----Rock Size------------- . -------------------------------- Distance to nearest: Well __-_.__-____:_.----------------------Foundation--------------------------Prop. Line_________________-_-_____. REPAIR/ADDITION (Prev. Sanitation Per t#-- ____---------------Date----------------------------------------------) Septic Tank (Specify Requirements)._-_I A---- � ,�- - ---- _-_ Disposal Field(Specify Requirements) -1-_ .. __ ---_ __ ..__ __ . ------ ---------- -- . .. --------------------------------------- ---------- = ------------ ----- -------- ---- ---- --------/X! ------jo� ---- ---- ior - .r- -`.. :,- ► "'^"�' ------- -- ------- (Draw existing a�required addition on reverse side) 1 hereby certify that 1 have prepared thapplication 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, 1 shall not employ any person in such manner as to becom subject ko"',W-orkmanl..Compeosation laws-;of California." - Signed---- t -1 - ,, _"7"< ;,� -- BY * Title---- (if itle__ --------------------------------------- (If other than owne FOR DEPARTME§LLUSJE ONLY APPLICATION ACCEPTED BY-- - .-- ----- --- ----- -------_ +_ - ---------------------------' DATE.------ - = fes =-- ---------- DIVISION OF LAND NUMBER-=- ----- -- ---------------- ---------- --------------------- -------------------DATE------------------- --- ADDITIONALCOMMENTS_-- --- - - - ---------------------------------------------------------------------------------------------------------- ----------------------- - - ------ ------------------ ------------ ------------------------------------------------------------------ -------------------- --------------------------------------- ---------------------------------------------- - - ------ --- -- --------------------------------------------------------------------------------------------------------------------------------------- -------- ------------------------------- - -- -------------------------------------------------------------------------------------------------- ------------------------- Date. --Final Inspection by: EH 13 24 i " N JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M