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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------- � (Complete in Triplicate) Permit No.- 7.7._ __-- -J_G O ------------•-------------------------------------------- Date Issued__g1__f/79- 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: JOB ADDRESS/LOCATIO '7 -- ---------- ---------- L?-,/G 7f_'_------ CENSUS TRACT Owner's Name------ 7 ----------------------------------------------------------------------.Phone-------------------------------------- Address------- p� 7 ------- ------ ---- -� A City--- s-------------Zip----- a------- Contractor's Name--- ------ --- --- I ' �� w F""�°� 4�a License # 2 Phone Installation will serve: Residence ❑ Apartment House.❑ Comme�flal ❑ Trailer Court ❑ Motel ❑ Other_ Number of living units:----- --------Number of bedrooms..,----Garbage Grinder------------Lot Size--------Z-0-0---- ________________ Water Supply: Public System and name------------------------------------------------------------ --------------•-------------------------------------------------------Private Character of soil to a depth of 3 feet ': Sand F] Silt❑ Clay ❑ Peat E] Sandy Loam ❑ Clay Loam E]Hardpan Ld Adobe F) Fill Materia l--------.---If yes,type________________________________ A. (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,) C' PACKAGE TREATMENT [ ] SEPTIC TANK [OTI Size-1ya 11__t_4-1_ ___. e------------------Liquid Depth-----44 ----------- _.__ C Capacity__L64_: --------Type-_f Material------ ......No. Compartments-------"I ____________________p. Distance to nearest: Well______________ - Foundation....__.._]___-_-_-_-_---Prop. Line--__--4------------------- LEACHING LINE [t� No. of Lines___________ ______________Length of each line.....___ -_p- ------------ Length __.___ _2G-__--------------------- 'D' Box-_._I------Type Filter Material-_-_- 5�__�-----Depth Filter Material--------�_�1__ ____________________________________________e. • C Distance to nearest. Well-------.7rr_P.-------------Foundation______---1t!_.*-____--_-_-Property Line------ __________ ___________� SEEPAGE PIT [� Depth-_L_S 1--__Diameter.3_3__-�__----Number---- ___________________ ` /f Rocl4Filled Yes No JWater Table Depth------------j!1;2a__.--------�-------------------Rock Size-------- - -------.�--c�-- ------------------ f Distance to nearest: Well----------!1_bd----------------------Foundation----'b...........--.Prop. Line_..__._.__.---_____. REPAIR/ADDITION (Prev. Sanitation Permit#___________________________________________________Date____---._------_-________._-•-____.._____...__) SepticTank (Specify Requirements)------------------------------------------------------------------------------------------------------------------------------ ---------------------------- DisposalField (Specify Requirements)------------------_- -------------- ------------------------------------------- ............... •------------------------------------ --------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) I 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: "1 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 Workman's Compensation laws of California." Signed---------- ------------------------------------ Owner o� By----------------------------------- ------------- -' '� - � -- ----Title---- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------- -------------------_ -------------------------------------------------------------------------DATE_.-------------------------------------------- DIVISION ATE.- .-------------------------------------------- DIVISIONOF LAND NUMBER----- -------------------------------- ----------- -----------------------------------------------------_DATE-------------------------------------- --------- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------------------------ ---_----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - --- - --------------------------------- -------------------------------------------- - ------------------------------------ --------- Date. fFinal Inspection by:. = EH 13 24 _ fN F&S 21677 REV. 7/76 3M