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t .. FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ----- (Complete in Triplicate) Permit No._7f- - - 5,-y 7� This Permit Expires 1 Year From Date Issued 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 Regula#ions": Q JOB ADDRESS/LOCATION 77.__. i a 7 -74 -------- -------- - +� CENSUS TRACT r ' Owner's f9 ----------- ---- r ---------- ----- ------ -------- --------- � ..7� 0 8 �� Phone -------- Address-. - ---- -Cit - Y Zi -- --- --------------- P -- --- ------ ------ --- Contractor's Name - ---- --- ---- ------ --- -- -- --- -- ----- -License #_2.7�J_�-9----Phone- �__`.2e6 c "f Installation will serve: Residence R--'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------- ------------------------------------- Number of living units:----/--------Number.of bedrooms.__ Garbage Grinder------ ------Lot Size..._,,��O_---..__ Water Supply: Public System and name_____________ Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay -------------------`--------------Private * y ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ElAdobe ❑ 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 - - --- S. -----------------Liquid Depth.------------- -------TYPeCa acitYy -------- Mate-rial --No. Compartments-------=---92---------- Distance to nearest: Well. 34 Q----------- ---------------Foundation___/!�_----__ - �� r *�,," LEACHING LINE Prop. L1ne..J1�w±* j [� No. of Lines__..___________________Length of each line_�5_��S � Total Length.../�8_ 'D' Box...- --Type Filter Material..Sf. &� P t' -_ .l Depth Filter Materlal____,�___________ Distance-to nearest. Wel l.__ C_C � � -- ------------------ SEEPAGE PIT P< Depth,-�� Diameter . --_------------Foundation....A --------_---- -.Property Line-- ------A! — --- ------ .--- _ -`3-- ---f----Number------1;�--------------------- r E/ Rock Filled Yes ' No ❑ Water Table Depth--------- C1_v________________ ------------ Rock Size---.s2_ C_ ---------------------------- istance.to nearest: Well--- ------ - -- < < ------Foundation--- Arop. Line. REPAIR/ADDITION (Prev, Sanitation Permit#--------------------------------------------------- Date.----- ------ - - ------ ---) Septic Tank (Specify Requirements)._____-------------------------------- t= -�-- - --- j -....�-.—.-�_ Disposal Field (Specify Requirements)____________ ---------------------------------------------------------------om __________ _ ----------------------- ----------------------------- ------------------ (Draw existing and required addition on'reverse side) -------------------------------------------- I hereby certify that I have prepared this application and that the work will be dome 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: "I certify that in the performance of the work-for which this permit is issued, I shall not employ an to becom ject to War an's ompensc�tion laws of California." P Y Y person in such manner as r Signed C ---- ---- --------- ------ Clwner ------- By--------- --- ------ ------ -- ----- ------ Title------- - - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_..___._ DIVISION OF -- L AND NUMBER - r DATE . ADDITIONAL COMMENTS--- r _ DATE ------ ---------------------- --------- i/ SIC - -- - - - __ _ ---- - -- Ov -------------------------------------------- -------------- -------- ------------------------------- Final Inspection b - ------------ --------- - -----Date--- EH 13 24 i SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M