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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit ----------------------- ------------- ;-_x-_77 - -- This Permit Expires 1 Year From Date Issued Date Issued_.;77,1:d_-_7.? 7 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/LOCATION. - ]7_ ----- -----------)---- -------- ---- - CENSUS TRACT Owner's Name----_---- -- -------- ------- ----- - -------------Phone ,* r -------------------- Addressl�CitY Zip --------------------------- Contractor's Name_---- ! _._ ------- License #_Zr� Z7_._ _Phone---------- ------ ---------' Installation will serve: Residence ^' " ` # m : [ /Apartment House.❑ Commercial ❑ Trailer Court ❑ ...; Motel O"y 5 !! Other------- - - ------------------- ---------------- 7 ' , ; k . Number of living units:-------[--------Number of bedrooms-____Garbage Grinder=._:_____.__Lot Size________ { - ----. Water Supply: Public System and name----------- -!-- -- ----- # y ,1 J g w - _ ----------------1_____-- -----------------------------------Private F>A� Character of soil to a depth P0,feef_ _Sand,' izsilt'❑ :Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ `! v ; Hardpan EK Ad�obe�(] —Fill Material-'_1._ If yes,yes, type--+---------------------------- t (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 seep age it permitted if public sewer'is available within 200 feet,} PACKAGE TREATMENT [ } SEPTIC TANK [; . .Size$_ �`; `'{ ` --- - --..5� - -- - ----Liquid Depth 7 Capacity.._ Er. YP T ,e-- -- No. Compartments ^ Distance to nearest: WellC-- �_ ' ', rFoundation:---- 1© LEACHING LINE. [ No, of Lines.:_:___-;-.3: t.f - ----Prop. Line---------- --1-^"-------- _ _____Length of each line.__.: _ Total Length._- 1_zG_ - ( D' Box-_ ........Type Filter,Material'------��___�__ Depth Filter Material.-_---f_ --____-. " F f. ___ Distancetofiearest: Well_ ___ -Q `-_„Foundation-.___. __ _______.Property Line_.____S�_ - --".-_""-- SEEPAGE PIT [ Depth_=? _Diameter r,- ---------Number__.____ �� _ _ Rock Filled Yes-�N0 [ Water Table Depfh'- '-;-- 0- -----------------------------Rock Size._1-_J�_ p Distance to ne&e'st�Well_:.___1,Sa" h�' : � -----;-------------Foundation.--��-- =- ------.Prop. Line---/------ ------ l REPAIR/ADDITION (Prev..Sanitation'Permit 417 "`` --- ------------- -----------Date------------- --------------- Septic Tank (Specify Requirements)---------------------------- --------------- .-. Disposal Field (Specify Requirements)---------;.------------ - ---------------------------- ---- ------------------ t _ - _____________.-- _____-. 5 _________________________ _ t (Draw existing and required addition`on reverse side) I hereby certify thatl 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: F "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.Workm Compensation laws .of California." Signed-=------ t - -------- - -- wriev BY = -�..T '(If other than owner) :. ._ __ ' s t -4 V } rFbR`DEPARYMENT USE ONLY APPLICATION ACCEPTED BY--------- ------ _ -""- - , - -------------------- -------------------------------- -DATE.--_-/1_--_77------ DIVISION OF LAND NUMBER------------- :: --------------'::----------° - ----------- -------------------------DATE - ADDITIONAL COMMENTS______________ - - -- - ------ --------------------------------- - ----.--- -----------:--------------- - ----- -- --- - --- ------------------ ------------------ -- -------- � -- ---------------------------------------, .Final-Inspection bY -- -7------------------ - -- _ _ - " Date.. err t3 sa SAN JOAQUIN LOCAL HEALTH DISTRICT"" Fas 21677 REV. 7176 3M J