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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT c IComplete in Triplicate] Permit No.__77-_%� -•-•----------------- ----------------- ----------- ----- This Permit Expires 1 Year From Date Issued Date 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 Regulations: JOB ADDRESS/LOCATIO _5 -- - ----"--/G---- /f-- - - ---------------� -- ----- CENSUS TRACT.-------.-- ----- s Owner's Name.. -------------------- ----- ------------------- Address-. ------------- Phone Address ---------- ------------------ ------Cit ---------Zi -- Y P Contractor's Name - ------ G`-="----- --� -------------------License #" a .?_ --Phone----------------------- Installation will serve: Residence [� Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- -- - ----------------------------------- Number of living units:-----1--------Number of bedrooms.-„j.___Garbage Grinder..------- -Lot Size..---.. "---`'` ------------------"------- Water Supply: Public System and name-- ---- ----------------------- -------------------------------------- -----------------------_------------------------- ------Private Character of soil to a depth of 3 feet: Sand F] Silt E] Clay F] Peat ED Sandy Loam E] Clay Loam F-]Hardpan [ 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-tankor seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ti ----------------------------- }} Liquid Depth -` ---------------- Capacity.11. 6.0--------Type-- -""-"- Material- _.-- - -- -- ~�.No, Compartments.---------- -------------------.\ Distance to nearest: Well-------- ------ `' - ----------Foundation-_----_1-Cl-_�--------.Prop. Line_._._J----_---.--.--_--- LEACHING LINE ✓� .3_--------_:_Length of each line ------------------- -------------Total Length Z'Q [ Na. of Lines ------------------------- 'D' Box--------I---Type Filter Materia ----------- ----Depth Filter Material------.I - `_.____ .""-.---------------------------- r Qistance to nearest: Well_______�_" N___..--Foundation------�-ry Property Line.--.-S- -" SEEPAGE PIT [ ] Depth . - .----Diameter.------ _ umber---.------_�------ ---------- Rock Filled Yes No EE Water Table Depth--------------110---I---------�r--------------------Rock Size 1- �-----X--3-------------------------- P Distance to nearest: Well---------t-0-0-----k-"------------Foundation------L_0----------------Prop. Line------ _____----------- REPAIR/ADDITION (Prev. Sanitation Permit#- Date__..____-_.."".."--..-_ ) f- -------------------- SepticTank (Specify Requirements)---------------- ---- ------------------------------------------------------------------------------------------------------ -------------% y Disposal Field (Specify Requirements)----------- ------- ----- ------------------------------- -------------------------------------------------`------- ----------------------a ----------------------------------------------- ------------------------------------- ---------------------------------------------------------------------------------------------- 4-- ------------------------ ---------------------------------------------------------------------------------------------------------- (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 Coun--- 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------------- -------- ---"------- v - Owner By----------------------------------------- '--L----------------Title.".�$At w' -- - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -------------------- ----DATE DIVISION OF LAND NUMBER _--_ -- -----. . -------------- - --- -------------------------------------- -------DATE---- ------------------------------------------- ADDITIONAL --------- --------------------------- ADDITIONAL COMMENTS. ---------------------------------------I--- ----------------•----------------- ---- ------------------------------------ -------------------------------------------------- ----------------------- r ------------------------------------------- ----- ---- - - --------------- ------------------------------------------- ------- -- ----- -------------------- --- P Y=-------- Final Ins ection b '----"---------Qate..""" . -:�' . ---.� - l -..I EH 13 24 SAN JOAQLJIN LOCA EAL7H DISTRICT F&S 21677 REV. 7/76 3Mf