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i ,f FORAFFICE USE; APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: [Complete in Triplicate) Permit No.--7 -� � 7-- ----------------------------- -- ----------------- ' Date Issued-,--:_3';;'Y-- --------- -- ----------- --- -- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for 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: „ 00 JOB ADDRESS/LOCATION � R p ----- -""- -- ----------------------------- . .. -- - --- � - T -- -- ---- Owner's Name 71 --� i _ e. ^ Phone Address------" -- -- Z. --•--- --- -- C tY --cc---- --------- - Contractor's Name--} " - -- ---I---- •----- 2--2-----------la_ ---Phone--- ----------------•- I i : .. ... ------------ Installation will serve: Residence ❑ Apartment House.❑ Commercial M Trailer Court ❑ Motel ❑ - • Other_ Number-of living units:---`'" Number of.bedrooms _.-- ----Garbage Grinder".-:---------Lot'Size--------- -- --------------- .:-- ----------- Water Supply: Public System and name---- _---- ------_----------------------- ' ----- Private--€--- ��A t Mard an et: . Sand [] Silt❑ Clay ❑ Peat Sandy Loam` Clay Loam ❑ t o Character of soil to a depth ofp3 f Y• P ❑ Adobe ❑ FilI 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.) x NEW INSTALLATION: °(No'septic tank'`or see age .pit permitted•if.public se er is available within 200 feet,) t PACKAGE TREATMEN_ T [ ] SEPTIC T ,ANK .[ + Size-1 �s°d f -�''� s l `�� , ._ ---------Liquid Depth----- -------------- - - Capacity--I.;La:Q,."-_--:.Type----- -Material ._ LNo. Compartments-----l'"------"------------ t i Distance..tonearest.:.Well-.......---- -e2-o----__------__.-------_Foundation----- ... --.Prop. Line------ ----_------__---. r LEACHING LINE, [, No, of Lines.--- I--------------Len th of each lin..:------ - ' g ------.Total Length.-.----Y-0------"-- ------ - ! p J aterial.... ---If Y ------------------------------------¢ i D' Box_---- _.Type Filter Material-.---��_�-- -.__ Qe th Filter M � - • Distance.to nearest: Well J..Zb Foundation -d- Property Line sr _ `--- -- ---- SEEPAGE PIT [ Depth-� Diameter -__ -.Number.- _"--- /-=--------- ---- Rock Filled Yes ❑ No ❑ Water Table Depth. Size Distance to nearest:WeIL`._--- '-0-'----- ---------.Foundation-- __--.-` ---------------PipLine----- REPAIR/ADDITION (Prev. Sanitation-Permit*---------- - "------- ---------------Date-- _ ) Septic Tank (Specify Requirements)__"-- -------------- = ---------------------- --------------- -------------- - ----- ------------------------------------ Disposal ---------- --=------ - ------- Disposal Field (Specify Requirements]--_ ----__ . - - ------------------------ ------------- ------- ----------- ----------------- ---------------------- ------------------------------- 'r. r .---- r (Draw'ezisting and required addition on reverse side) 1 hereby certify that-] 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 pei-Formonce-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 Compensation:;laws of California." i Signed-=--------"----------- ------ ------ I ---------- --- Owner BY e - .Te_ {If other than:owner) FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY .[�,.; `---- ------`------ -- -------DATE.. - 1 ------------- DIVISION OF LAND NUMBER -=---------- --------------------------------------------- -- ----------------"DATE -------------- -- ----------------------- ADDITIONAL COMMENTS------------= - ----------------------- --------------------------------------- ------------------- ----- -------------------------------- --------------------------------------------- -- -------------------------------- ------------------------------------------------------------ --------F---- ---- -- .- --------------- ----- ---- ------------------------------------ -------- ---------------- ---------<.----------------------------- = = ------------ -------------------- ------------------------------------ Final Inspection by -----------= ------- "" EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV- 7/76 3M