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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �• ' (Complete in Triplicate) Permit No-------------_--_---- ----------------------------------------------------- Date Issued._T;�`.._.9-77 -------------------------------------------_------------ This Permit Expires i Year From Date Issued Application is hereby made to the San Joaquin Local Health District fora. 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/LOCATIO fr- X - L CENSUS TRACT Ch+vner's Name � i -� hone ------------- Address ----------- Address-- --..�-----4 ------t---------i-------- city - -._._%-zip T ------ Contractor's Name---- ---- � fo, ---------- ---,------- e--------------License #�739-----Phone %eS�-117f/e Installation will serve: ! Residence Apartment House.❑__Commercial.© Trailer Court ❑ ` Motel ❑ Other------------------------------------------ R----- & f tom` Number of living units:-- / -----Number of bedro ms---/-- Garbage Grinder----.----.--Lot Size_-_-+ ___. .1�- --------------- ` Water Supply: Public System and nam e --'C-le'__ -----------------` 'v' ---------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ . Clay,❑ Peat ❑ Sandy!Loam❑ Clay Loam ❑ Hardpan ❑ Adobe Fill'MateriaL_.__.____._If yes, type______!--------I-------- -_ (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 seepage pit;permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Sizel------------------------------- --- -----------------------Liquid Depth----------------------- Capacity--------------------Type [-Material--------------- ---- No. Compartments--------------------------------- �. A LDistance to nearest: Well------------------------ -------- Foundatio,n_:----,-------------------Prop.. Line--------------------------- LEACHING LINE [ No. of Lines-----------------------------Length of'each line----,------_-..-_.----_.__-----Total Length.______.____________--__--_---.-.-_ r'D' Box-----------Type Filter Material--------- -------Depth Filter Matericyl-------------------------------------------------- �m. 'Distance to nearest: Well -----------------_--------Foundation-----------._4_- --------Property Line------------------------------------ SEEPAGE -----__-----._ _-_-.SEEPAGE PIT [ ] Depth----------------Diameter-----.--------------Number-------------------------------- Rock Filler! Yes ❑ No ❑ WaterTable Depth.--------------------------------------------------------Rock Size----------------------- ------------------------ Distance to-nearest: Well__- :`- -------------------------Foundation*------------------------Prop..Line----------------------_---- REPAIR/ADDITION (Prev. Sanitation Permit#_ — ----__---:-Date.:.___ eo----------------- ___-A Septic Tank (Specify Requirements)____--______________ Disposal Field (Specify Requirements)._ -._. -- --- = - --------------------------------------------------------------- _(Draw xis_:_.g and required addition on reverse side) 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..Regullations 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, I shall not employ any person in such manner as to become su to Work s=lotion laws of California." , Signed- - ----- -- 1 d-- ...'' f -- --------------------Owner BY------------------------------ - /. - - - •-------Title -- ------------------------------------------- ( other than owner} FOR DEPARTAiIENT USE ONLY APPLICATION ACCEPTED BY-----1'" " --A'T� - -------------------------------------------------------------------DATE.---�'--~•�-y - ------------------- DIVISION OF LAND NUMBER ----------_--- -_--- .DATE______._____._____ -------------------------------------------------------------------------------- ---------- --------- ADDITIONALCOMMENTS---------- --- 1 --- -_- ----- ------------------------------------- ----------- ----------------- ---------------------------- ---------------------------------- r w 10 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- -------------------------------------- -- - - ----- -- - Final inspection by: ------------------------------------------------------------------ ��,1 Date _ EH 13 24 . F&5 21677 REV. 7/76 3M SAN JOi4QUIN LOCAL HEALTH DISTRICT �r