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FOR OFFICE USE: / FOR OFFICE USE: !/ APPLICATION FOR SANITATION PERMIT ------ -�--------------------------- -- -- {Complete in Triplicate) Permit No.7 _1__3_p__ ---------------------------------------------------- ------------------------------------------------- Date Issued_L--f',;7_ __ __________________________________________________ ______ I 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 compliancX with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ON__�65�._ - .---r>�04--_--------_ - - -- - -- ,_..GENS PhoneACT------------------------------ s Owner's Name------ ----- ----� ------- ---- ----- ---------- ---- - Address-------------Q__ ..T7 _lit A_ -c ------------------- CitY----------------------------------- zip Contractor's Name......�_�_►.+.r_+�__s--.-ie4 ----------GQp----- -----------License gZ 2ZC Phone---------------------- Installation will serve: Residence [7� Apartment House.[:] Commercial ❑ Trailer Court ❑ Motel ❑ Other------ -- -- ---- - ------------------------- / / Number of living units:------ _.______Number of bedrooms- 1---_.Garbage Grinder------------Lot ------------_________________ Water Supply: Public System and name----------------- ----- -- -------------------------------------------------------------------------------------------------------Private 21 Character of soil to a depth of 3 feet: Sand ❑Silt❑ Clay ❑ Peat E] Sandy Loam E] Clay Loam EJHardpan ❑ Adobe Fill Material-- ._ ----- 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,) 00 PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------,_----------------------------------------Liquid Depth---------------------------a- Capacity--- ---- ---- -------Type_--------------------Material-----------.--------------No. Compartments----------------------------------- Distance to nearest: Well _Foundation_------_------------------Prop. Line------------------------- -. LEACHING LINE [ ] 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--___ 0--__3 __----------) f Septic Tank (Specify Requirements)------------------ ------------ Disposal Field (Specify R irmen s)-- � •' - - --------------- -- ---- - ----cif------- ------- r - (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: "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 subject to Workman's Compensation laws of California." Signed---------------------------------------- ----------- --- Cri+vner ;e4 BY [Title ' "`" ----------------------------------- -- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -------------------------------------------------------------------------------DATE.----- -_t�.Z_ I ---------- ------- DIVISION OF LAND NUMSE ----- --------------------------------- - ---- -- -------------------------------- - ----.DATE------------------- -- - ADDITIONALCOMMENTS - -------------------------------------------- ------------------------------------------------------------------------------------------------------- -------------------------------------- -- -------------- ------------------------------------------------------------------------------------------------------- ------------ ------ ---------------- ---- ------ --------------------------------- �----------------------------------------------------------------------------------- ----------- - - Final Inspection by: - Date -5� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M