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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- ------------------------ ------ ---------- ---- Permit No.-.7-7_--6G� , ------------I--------------------------- -------- -------- - (Complete in Triplicate) ' Date Issued---7'��..�7 ----------------------- --------------------------------- This Permit Expires 1 Year 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: l JOB ADDRESS/LOCATION - ------ ----- --- ----=------------------ •----------------=.CENSUS TRACT------------------------ Owner's Name..-- CSC -- ----------------- --- --- ---- --"--------------------- Phone--------- -------------------- Address--- f. L City dip �y Contractor's Name---- ------ ----License #---3 _,9.a.2,4"Phone-.------------------------------- Installation will serve: Residence ❑ Apartment House.E] Commercial [] Trailer Court ❑ ` [ . s Motel ❑. Other- Number ther Number of living units:----J--------Number.of bed rooms.___ _Garbage Grinder------------Lot Size-------- - - __-_._._-__.___ t Water Supply: Public System and name------- --- --- ------------:--------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ O Hardpan Adobe ❑ Fill 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.) " NEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) i PACKAGE TREATMENT SEPTIC TANK [ Size- C i 7 _ ----------- ----------------Liquid Depth._:�e_.__..___________- Capacity- Type- - Material----- - ---No. Corrspartments.- ---------------------------- € 3- Distance to nea est:;Well.___ ___� - Foundation.____ G' ___,Prop. Line_.__-� _________ LEACHING LINE [/No. of Lines----------- ____.____,_.Length of-each=line'____._-:_._ Tota Length g_d '____- - ' ' Al `-_~~ � f, D' Box---- - ----Type Filter Material:-------- -_�---Depth Filter Material------:- - -fx`----------------------------------------- -- f ! Distance to nearest: Well_:_____ !?_ Foundation------�Pj(�_ =__.PCoperty Line__._____�� _-_ ....... SEEPAGE PIT Depth---- _Diameter_______________ __Number _.------I------- Rock`Filled Yes N0E Water Table Depth --- .......... ---- -- / Rock Size. ------------------ � : Distance to nearest: Well-------- Foundation------- ---- -------- Prop; Line'__----------------- ! REPAIR/ADDITION (Prev, Sanitation Permit#-------------------------------- -- -------___---Date.---_-----------.-----------------' Septic Tank (Specify Requirements)-----= = ----------------- --- ---------------------=---------------------------------- -------------------------=-=------------------------------------ Disposal ------------------------------ ----Disposal Field (Specify Requirements)------------------- = ---------------------------------------- i- ------------------ ------------------------------------------------ ----- ----------------------------------------------------------- - ---------------------------------------------------------------.---------------------------------- --------------- --------- ---- % ` ,. (Draw existing 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 Regulations �of the San Joaquin Local Health District• Home owner or licensed agents signature certifies the following: ..- r: "1 certify that in the performance of the work`-for which This permit"is-issued, I.sholl not employ any person in such manner as to become subject to Workman's Compensation laws�lof.,Calif ornia. f .. .- —. _ Signed----------------- ---- ---- ------ -- --- �.' ...---�----__: Ownar. BY --`-- -- - `y f �� Title.- (If other than`owner) _�� FORrPEPARTMENT USE ONLY i APPLICATION ACCEPTED BY----- -- - --'- -- ------- - -------DATE:_.. 7.(Z_6/ -. DIVISION OF LAND NUMBER.. ------ ----DATE----------------------------- - -- ADDITIONAL COMMENTS- ---- ----- -------- --------- ------------------------------------------------ --------- ---- -------------- ---- ------------------------------------------------- -- ----------------------------------------------------------------------------------------- ------------------------------------------------------- -- ---- ------------------------------------ --------------------------------- -______________________________________________________________ _____________________________________________________________________________________________ __________________________________________ __ f._ ________________ -------------- _ -----------------------------------------------------------------------------------------------__-- __________ _-__-- _______________________________________________ _ _ __ ______ -------------------------------------------------------------__.-_----------_____-___.____________ Final Inspection by------------ - - - ------------------ -----------------------------------------------------------=----Date- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8S 2i 677 REV. 7/76 3M 1