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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: 5, p (Complete in Triplicate) Permit N0.7-f_1 Date Issued_/a-7-//:7, � Z -.- This Permit Expires 1 YeAlfar 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 Regulations: JOB ADDRESS/ O--C--A---TI-ON-_--- -] r�. t - k .t Owner's Name � ------------ - -- -- ----CENSUS TRACT-------- -------- --------- r. -------------------------------------------------- -- -- ------------------------- Address-------- l_�- Phone_ ---------------- Lf C --City Zip.- (�------------------- Contractor's Name------ --------> --74-------- Q- --------------------License � Installation will serve: Residence (Z/partment House.❑ Commercial L) Trailer Court ❑ Motel ❑ Other__--.___."_---------------- ................ Number of living units:- ----.--Number edrooM3----?_-----Garbage Grinder Water Supply: Public Systemand name ---- �� / r Gam ,- ---------- --------------Private [JCharacter of soil to a depth`of 3 feet: Sand ❑ Silt Clay [:1 Peat❑ Sandy Loam ❑ Clay Loam ❑ ~� Hardpan ❑ f Adabe FEII Material) !]-ff yes, type.--,-__________________ (Plot plan, showing size of iot, location of system in relation to wells, buildings, etc.Aust be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer i� available within 200 feet,] PACKAGE TREATMENT [ ]` SEPTIC TANK '""Siz"e"`-_______-______. __ ]' ----------- -----------Liquid Depth----------------- Capacity-----------------------Type------------------ ----Material----------_-- ------=---`No. Compartments------------- 0 -------------- Distance to nearest;,Well_--.___--- ______ Foundation-------------------------Prop. Line------------------------ LEACHING LINE [ ] No.:of{Lines-----------I_____I--------- of each lines_ -- Total Length ----------------------- 'D' Box---- .___Type Filter Material--------------------Depth Filter Material-------------------------------- I x- � _ ------ --------------- ------ Distance to nearest: Well..-- v-',a?- Foundation---.--_-- " Line--- - ------- -------------------------------- SEEPAGE PIT Depth.-----1-___ --Diameter--------- ---------- m --------- -.Property ----------------- __---- Rock Filled Yes ❑ No ❑ i Water Table Depth----------------------- -------.Rock Size----------____-- ------ ----------------------- Distance to nearest: Well-_------------------ - ------Foundatii,on--_---_----------------- ---- -------• Prop. Line----------------- ' � ------_� REPAIR/ADDITION (Prev. Sanitation Permit#-------------------- -- ----------'------------- --Date-- ---------- --------- Septic Tank (Specify Requirements)";,"______________ 5 --------- Disposal Field (Specify Requirements)_ D f I -------------- = ---------------- ----------------------------------------------------------- . - - --------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this-applicationand-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: yy "I certify that in the performance of the work for which this permit is issued, I sh�il not employ any person in such manner as to become-subject to_Workm 11 Com sa ion laws.-Of,-California." Signed--------------- - --- --- 4v ------- Owner BY - - ----------------- ----------------- ---- - -- - ------------------- "'00 ------- -Title ll other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ----- - DATE. ----- -- 7 ----------- DIVISION Of= LAND NUMBER.____ __________ _ - --- _ -------------------------------------- - -- --------- ---------- ATE------- --------- - ------------ �--- ---- ADDITIONAL COMMENTS---�`Q_��.. Q¢ dt-- � �� /"Z ------------------------------------------------------ ----------------------------- -- -------------------------------------- ------------------------------------------------------------ 3 Fina! inspection by - - ----- --------------------------------------------------------- --------- Date------- -- - - --------------------------------------------------- -------------- H 19 2a SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 R1W76 3M