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FOR OFFICE USE. 1 APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ........ (Complete in Triplicate) Permit No.79,-47,0_--,..... i This Permit Expires 1 Year From Date Issued Date lssued._5�-3i-74_.. Application is hereby made to-the San Joaquin Local Health District for a permit to construct and install t This application is made in compliance with County Ordinance,No. 549 and existing Rules and Regulations: work herein described. JOB ADDRESS/LOCATION. =�a-��...e4 --- ------------------•-- •-- •-- .......CENSUS TRACT.............. Owner's Name.... .--.-� Address... .......... City.. ..Zi Contractor's Name......................./. .. f Ph License # G 3 , I Ct/�a •• one Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other----- - ----------- Number of living units:......._`._..__Number of bedrooms___._ ...Garbage Grinder------------Lot Size------ - $ f Water Supply: Public System and name..................-....... Private ------------------------------------------ --•-------- -----. --. Character of soil to a depth of 3 feet: _ Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material....... ....If yes, type (` t -.-•--------•�------- (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 a a fable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ii Size-------- -- -- ----------- - - ------Liquid Depth.'-,-...........Type--------------- .......Material ...-.:No. Compartments -------:.............. .. Distance to nearest: Well-'------------------------------- ------•--Foundation------------ ---- --..._Prop. Line..---....__............ LEACHING LINE 1 .. [ � No. of Lines. - - ----------------= -----Length of each line ••-------- Total Length . ........................ 'D' Box........ _.7ype Filter Material Depth Filter Material.............----------------- Distance ..... .Distance to nearest: Well..................7 '°-.-.Foundation ...:..Property Litie............. SEEPAGE PIT .' ' ..-""":-.� _,- . ,�-- ,I,1 Depth --- Diameter---•_---- ..Number- ---:--...-----•---••------ Rock Filled Yes ❑ No i Water Table D1epth--------------- = = ------------------------- :.Rock Size......... --------=----•-•----- ` Distance to nearest: Well •---- . -- _"'"7 'ttPF _„ Foundation. .....Prop. Line- --------- i REPAIR/ADDITION (Prev. Sanitation.Permit#_______________ Septic Tank (Specify.Requirements).......: ......... I ... •-------- Disposal Field (Specify Requirements)..._..... __ ° .................. , . - �. /0 ter ----------------- --------------------- ............. ------------•..............---------------------`..........-..------ (Draw existing and required addition on reverse side) f f I hereby certify that I have prepared this application and that the work 'will be done in accordance with San Joaquin County Ordinances, StateLaws, and Rules and Regulations of the San Joaquin Local Health Dlstrict. 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 sub) to Work rn s Co '3ensation laws of California." Signed l ,. Owner. By..----- --l/ t---- _ ._.. . ---Title-------------- _ . - ---------- -- .. _ s---------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY," ------------- I--------------�- ........ .......-......................... ---------•DATE.------ ---- DIVISION OF LAND NUMBER----------------- ------------------------.-----DATE .....----•----- - p �Q::l: ::::: ::::::: :, ............ ...... •..-.._._..i_. _.-._.._-.___-....__.__ _ ADDITIONAL COMMENTS- ---------_-------------�. ------- ------ -- --------- �Lt` ..S �aryd -- ----------•------- -- _________------------------------- _ ....... .. .......................Y.._._____..._.-_____. ._______..----------------------------- _ ...__...k. ._ __ Final InspecTion by:. -------------------- - ate..c5 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F& 21677 REV. 7/76 3M