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FOR OFFICE USE: FOR OFFICE USE: Z 3� 4-10 7 APPLICATION FOR SANITATION PERMIT �y - - ------ Permit No.57 .�._.....f- (Complete in Triplicate) ---------------------- ------------------- Date Issue . ... 7 .................................. .........- -- This Permit Expires 1 Year From Date Issued Application1s hereby made to the-San-Joaquin Local,Health' District for a permit to tonstructyand install the work herein described. This application is made in compliance with County Ordinan e No. 549 and existing Ru es and / r Regulato :.T ..................JOB ADDRESSAOC .-,��AC Owner's Name..... .............Phone...q"- -,_, � ..... Address o * - ------ ---- ----------- - --- - City. ,:._..-. ziP .:. .... ( •-{ } Contractor's Name.......---I License #✓�1 j Phone._ Installation will serve: Residence❑ Apartment ou ❑ Corgmercial ❑ Wize_'300 vrt ❑ f Motel E] _Other...pro Number of living units:................Number of bedrooms.. ~_... .:Garbage Grinder----------..Lot , ..- . _-. .. Water Supply: Public System and name-- ------------- ------...._.. . - • ---- ----------L---------------------------- ----------- --- - Private [� Character of soil to a depth of 3 feet:, Sand ❑ Silt [❑ Clay E] Peat, Sandy Loam E] Clay Loam ❑ / L Hardpan ❑ Adobe ❑ Fill Materia-I.. _.°.....If yes, type-..----___:.............. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) C NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet, PACKAGE TREATMENT SEPTIC TANK Size ___ _.. 1 ... ...................Liquid Depth.F � � [ I e� 1 Capacity./.g..00__Type---^-/-�,r..----'--....Material-CA-7-L----•---:No. Compartments----- ---------- ----- -----t'{ Distance to neares Well.:_�f/ F----.... .Foundation.._f-Il . .............Prop. Line_. --.......-----� LEACHING LINE [ } No. of-Lines- ------ ....... ......Length of each line..----- .---------- ---Total Lenge .. -- .- ..-. --......-.-.._.. 'D' Bo T e Filter Material..-' . ] Depth Filter Material..... ... ..... ------.-- ----- pQ77 f -----------------------Property Line------------ ---- -----Distant to nearest: Well------------- .........Foundation..... --- Rock Filled Yes No r SEEPAGE PIT � j Depth...... .........Diameter----------._.- -..._:Number---e..._____._ ----.---___--- ❑ ❑ WaterTable Depth----•--------------- ------ - ----=---------- ---Rock Size........................... ------... -•-------- Distance to nearest: Well-- ------------------- -------Foundation---- . ..................Prop. Line.-------- ....... REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------- ---------------Date........•......-----------------------_-----j Septic Tank (Specify Requirementsl---- - ------ ----------------------------------- - -I •-•----------- ---------------------------------- ---------- Disposal Field (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 a "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 ensation laws of California." Signed--- ..... --- --- ------- ------------ ;-f0 er By------- ie ------------------- ---------- ..------------ -------- ( other tan owner) I: IFOR DEPA ENT USE ONLY APPLICATION ACCEPTED BY_ � ... ....-- -- -r--- €.................... ------ .DATE .. '.7 -..7.5.. DIVISION OF LAND NUMBER.'................. DATE....-................. " ADDITIONAL COMMENTS.. - --------- --- ...--_ . k ------------------------------------------ --------- ---------- ------ ----- ........ ...... l --- -.../� - _ Final Inspection b /< ------------- ---------------- -------------------------------- S. ----- . ..... ----------------- -------------------- --------- . . � .,..-6 77 RE- - -R:E V 7 17.6--3M -- i EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21 . 7/76