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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT b r w :.. ....... . Permit No."7f ....... (Complete in Triplicate) .................................................... Date Issued.2.77-3f:-,7�K ......................................................... This Permit Expires 1 Year From Date Issued ,... . 1 � . Application is hereby made to.the San Joaquin Local Health District for a•permit to con truc't.anci.instalk the work herein described. This application is made in compliance.with County Ordinance No. 549 and exist in Rules and Regulations: JOB ADDRESS/LOCATION...... .....CENSUS TRACT................................ Owner's Name..._ _�.. t -------- - ----"- ........I....... -- Phone............:.. Address.............. .... a i.._. � Zip lJ1._7/.Phone..9 L-...=l-�.....•-.. Contractor's Name.- License #.. Q / Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑.,, Other...,........... Number of living un its:......1..,_____.Number of bedrooms----:/..Garbage Grinder............Lot Size.___.__f� a ;/f ,;...................... . •. Water Supply: Public System and name,. ..:.'............ ... . Private•[j' Character of soil to a depth of-3 feet: 1 Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam Hardpan C] 1 Adobe F1Fill Material.. ._ ....If yes,type......... i (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,] Size. .- ...Liquid De th.. .' i PACKAGE TREATMENT [ ] SEPTIC TANK' [ ] '� � /I �-•-•�'�' '-"--"'-•"""--� -;�•--' p .Materiol..__.6 ••-_-_Na. Compartments..._. .._. Capacity..�..� ��-Type--- ,p..�.. .. �7 _ Well / (/............ .. ......Found`on:_e.V!........._..Prop. Line..-•---•-•---- ... ----••- Distance to nearest;. ...._ �g-� LEACHING LINE [ ] No. of Lines - ........... Length of each line.._..D."-p-••--...........Total le�gth .. .`-- �••• - 1 'D' Box..---. ..;.Type Filter Material..-.......... ..:•---Depth Filter Material._,_.. .. ....................... [ Property Line................................... �© !� Distance to nearest: Weil.----00.Q--.... ...Foundation----------------- p y ! SEEPAGE PIT ( ] Depth_.......... < Rock Filled Yes j�( No❑i ..Diameter.------ •---- :..Number.............:.•-,-•- .,-... . / ---------_-- 3 - -------------- Water Table Depth----.------ ........................._..Rock Size-.._-.�-... I Prop. Line......_. ...__.... Distance to nearest: Well-----------------------••--•-- • ...foundation..._....------.• .-. l ( Date.._'.....:. .............. .......1 REPAIR/ADDITION (Prev. Sanitation Permit#-_-."-"-"=-_•_:_:••--- --•-- `i Septic Tank (Specify Requirements)...?I • ---.....---•-- ------- •-----.. .. ... ..........----- _........................ •---.. ..... Disposal Field (Specify Re quirements)1............. ..................................t....: -------------- • -- .......... II ' ............. - ......... ............--"---..._..__......... ................. -......... .....- (Draw existing and required addition on reverse side) I I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County ations of the San Joaquin Local Health District. Home owner or licensed agents Ordinances, State Laws, and Rules and Regul signature certifies the following: sr-which certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner a! ). to become subject to Workman's Compensation laws of California." Signed ......Owner. . .. .. Title------------- (lf other than owne FO DEPART ENT USE ONLY DATE ... 7. . r.. . ?. '......:....... . APPLICATION ACCEPTED BY °Z.....--- ------ ----- . / I DIVISION OF LAND NUMBER.... . ------.... -- . . DAT .. .. ........ ..... ..... .....---- �- ADDITIONAL COMMENTS ....... I t_r - .................. -.......... ..-.- ....1.. W. M-V . ...-.. _ . ....... .-fes. ----...... �--�p. . .&d.•--- -- ------- -- ...lS....... . ................. ............ _---".. ................. .. --•-- ......Date......-Z- -_..... .......I.- Final Inspection bFSS 4161•! REV.7/76 r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT