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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANI1AIIIvo % PERMIT ••� Permit No_72Z ;777' (Complete in Triplicate) -- ------ ,� -- �7 Date Issued.._ _-__-_ .__- This Permit Expires 1 Year From Date Issued \pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordi ance/JNo. 549 and existing Rules and Regulations: OB ADDRESS LOCATION l' �., / 1 rj�� C led _ _.-- ._ _ CENSUS TRACT --.-.------------/----...... / IO^ +�b owner's Name /J-a. .. ... .... ... �- ` '/ - Phone -D_.-}----- ---------- �ddress C 5 5l v" ` /"�� 2 � _...City. L.RG:-cn - -Zip--¢-S- - . --- . . . .------- -ff f.. contractor's Name [.a (� ----.License #. ----- ---------------Phone _ .. ----- ---- nstallation will serve: Residence,] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑i Other . -------------------- -•----------------- '�Iumber of living units:............___Number of bedrooms ........ Garbage Grinder...._-----Lot Size -- -- -- vVater Supply: Public System and name------- ..------_- --------------------------------- ------ - - - - - -- -Private Cha-atter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-.._ ----------- -------------------- ____ -. ---.Liquid Depth Capacity Type ..._.... -- . .....Material------ ---No. Compartments t Distance to nearest: Well.....................................------Foundation ------------------- .- Prop. Line LEACHING LINE [ J No. of Lines ............................Length of each line-.._...___---_------- -------Total Length . 'D' Box Type Filter Material ._..._ ....... Depth Filter Material_--------------_._-_....-_._ Distance to nearest: Well.--__---_-------------__.Foundation_ _ ----- - ------------Property Line._._ SEEPAGE PIT [ ] Depth Diameter_.................Number -..__------_.---_.-_-__ Rock'Filled Yes ❑ No WaterTable Depth............................................. .......... Rock Size_..... -------- - .- Distance to nearest: Well-- --------- ------ --------------- -------Foundation ... ------------------ Prop. Line---------- REPAIR/ADDITION (Prev. Sanitation Permit#--------- ---------------------------------------Date .-------------------.._.-_-..-_- - --_ -) Septic Tank (Specify Requirements) --------•---------- •---t-=----------- Disposal Field (Specify Requirements) ........ - l a T a Com. - .. n --- - - (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County r,, Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent`t. 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 s lett to Workman's mpens ' n laws of California." SignedOwner ------- ------ ) Title (If other than owner) FOR DEPART T USE ONLY APPLICATION ACCEPTED BY DATE - - - DIVISION OF LAND NUMBER .- . . DATE---------------- _. ....._- � � ADDITIONAL COMMENTS - --- --- -•-------- ----- ------------------- ---- .......... --• ----------.-...----------•------------------- L�/ -•- ---------------------------------------- .------------------------------------------------•------------ . .. Da t .... --•------------•••------ -- ------- •-Final Inspection by:.--- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M