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! FOR OFFICE USE: FOR OFFICE USE: <<� t 3 APPLICATION FOR SANITATION PERMIT -- ----------------•----------- 7 9�� (Complete in Tripliicate} Permit No.._____ ______________ 77 This Permit Expires 1 Year From Date Issued Date Issued�a --- . Application is hereby made to the San Joaquin Local Health District•for a per �=t'rucf and install th work herein desc ed, '-This application is made in compliance with Cou Ordinance No. 549 and existing Rules and Regulations: - �� L n JOB ADDRESS/LOCAT N /. �J.1.c_/i_---------- -=-�- ----CENSUS TRACT ------- ---------------------- Owner s Name-- _Gt1un - Phone ----' --- --- Address- 0-- 7 ' /^ ---City ----Zip- Contractor's Name-----_-- -=-- d r: -- ..------ _License #_�_ � — y -.Phone _- - - �� .�- ---------- --- ` Installation will, serve: `1Y Residence �pci'rtment House.❑ Commercial ❑ trailer Court ❑ Motel ❑ Other -------- - ------ Number-bf living units:`.____/_-------Number of bedrooms, ------Garbage Grinder�__ _.Lot Size---- ------- Water Supply: Public System and name------ ------------------------------------------- -----f-------------------------------------------------- -00--------------------Private Character of soil to a depth of 3 feet: Sand ❑ Si Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan,❑ -Adobe Fill Material-..---------If yes, type-------------------------------- {Plot plan, showing sizeof 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 [y]� ize._ ---------------------------------Liquid Depth.__', .1 _____.__ Capacity __ p y_-- c v--"-___Type -Ad—material�� , '_No: Compartments-____ r �_ ,-- ' DI'Mrice to nearest: Well__--- �... Foundation ------------ Line.+ "~ _/ ---------------------- LEACHING LINE [y}' No-of tines__:_ ___ J-_ ____Length of each line,-- �_ --____.Total Length..-7d-J_____________________ /-- i/ ' vel, Type Filter MateriaL_�^_O_G_�___-Depth Filter Material._:/. _________.______.__________._______________________� Distao ne arest: Well---.--�-�-._______.Foundation--/v.- �---------:___.Property Line-- r 6 .0 SEEPAGE PIT [►�]�Depth.- _S' Diameter--_ -3--______Number-___--�_______________ Rock Filled Yes / i / 1� � _ Rock Size__. _- __ Water Table Depth - - -------�----------------------------------- -- /L-�----------------------------- Distance to nearest: Well--.._,� Q_____-___--_-.---_----.Foundation___/�_i_._________.Prop- Line___________________ REPAIR/ADDITIONPrev. Sanitation Permit#__________________________ { .:.. ., t. ate_ 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, U40e Laws; and Rules and Regulations of the. San,Joaquin Local Health District, Home owner or licensed agents signature certifies the following: 7 "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 -,fo Workman's Compensation laws of California." Signed--------- ---------- ---- ---- ------------------------------------ t l ----Owner --Title-- By - , (If other.than owned R:-.DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY_____ _ _. ----- -- - -- ----------------- -------------- --- -----------------------------------DATE.-yf_-�.-�-- =-�-� ---- - DIVISION OF-LAND NUMBE=R..___ -------------- - --- --- - --- -- -- --------------------------------------------------------- DATE-- ------ ADDITIONALCOMWENTS---- ---- -- -- - - ---------------------------------- i ---------------------------------- - ------- ------- ---------- --------------------- ------------------ ------------------------------------ -------------------------------------------- ! - ------------------------------------------ -- ---- --- ---------4-- --------------------- -- ---- --- -- -------- ------ ------------------------------------------------------------------------------------------------------------------- -------- Final inspection by:-- ---Date.-/---/-3.-__- ----- -- ---- -- --- ----- - - fEH 13 2e, SAN J AQUIN LOCAL HEALTH DISTRICT Fes 21677 Rev. 7176 are I l 60