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FOR OFFICE USE: :„ FOR OFFICE USE: APPLICATION FOR SANITATION PIERMIT ------------------------------------- - Permit No.7- ,? (Complete in Triplicate) ,-_)--"- --------------------------------------------------------- Date Issued...K7-,/2r_,78' ----------_------__------------------------------------ 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. tThis application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS/LO CATION._ . .Cc 1 = -- '------=---.CENSUS TRACT----- -------------------- O'_ --- - ----------- n _ Phone. - Address Owner s � � .� � -- - = City � --�- ---- - F. Z ------ ---------- -- -------- p _....f _ : ------------ Contractor's Name_____ _.. _....__.License # �r �--- Phone __7� Installation will sea e: Residence Apartment House❑ Commercial E] Trailer Court ❑ Motel ❑-- : Other-_- --------------------- = - Number.of living units:--,_ Number of bedrooms..,:_-Garbage Grinder.- .------ lot Size-__-_.:--------------------'_._._.-_____.._.___._,._____. __. -.S„ *e . i 'Water Supply: Public System and;name _ =-------- r Private ❑ Character of soil to-a depth of 3 feet: Sand ❑ Silt 0 Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan W. Adobe.❑ Fill MateriaL.:..___y_If yes,type________________________ (Plot plan, showing size of lot, location of system in relation to w`ells, buildings,Eetc. must be placed on reverse side.) a NEW INSTALLATION: -'(No septic tank "or seepage pit permitted if'public sewer is available within 200 feet,) [ ] ; PACKAGE TREATMENT [ ] , SEPTIC�ANK � ` � Size. ----" -------------�-------------------=------------ � Liquid Depth --------------- ----- - = Capacity ......... Type- ---------- -------- Material-----------------------:--No. Compartments----------:-------------------- - Distance to nearest: Well = a--------- ---------- ° Foundation_- Prop. Line- - r LEACHING LINEr [ .] No. of Lines:___ ` _____________Len-.Length of each line____„ :jV Total! Length..__._4/1-5— LE /1-5 W _____ ----- g ---------------- ----� 'D' Box__:---------Type Filter Material- "---_:._._"_ _.Depth Filter Material ---------------------- --------------------------------- - --- Distance to nearest: Well--------------------- -----Foundation ---------------------------- Property Line-- ------------------------____-- SEEPAGE PIT [ ] } Depth- .'S(----Diameter_.._ ----------Number_._-__------------------------: Rock Filled Yes [ No '_ � Well _.� e �:_.rWater,Table Depth---------- -------------=--------------------=------- = ----Rock Size_------`-------------=------------- ------------ ' Distance t. ., o nearest: .._--- ---- - ----- ------- -------------Foundation ------------ =-----`..Prop. Line-- --------- ---------- REPAIR/ADDITION Prev: Sanitation Permit-#-----1 .. ..:— Se tic Tank S ecif Re uirements ------------- _:.-- -:--- ----- - __ ��_ Disposal Field (Specify Requirements)!---- ---- ----------- -------------- -------- ----------- Z.- ----- - --- --- ------------ --------------------------------- -------------------------------- :----- -- ----------- --- ------------- -- - -------------- ----------------------------------------------------- -------------------•--------------------------------- ---------- -------------------------- - -- - --- -- --------------------------------------- -- ------------- (Draw existing and required addition on reverse side) , i ° I hereby certify that 1 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 J aquin Local Health District. Nome 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 gas to become .subject to Workman's Compensation..laws of California." i Signed-:-- --- - --- ----- te9--------- A---- - .------ ----. --- .-.---- ---- ---:- ----,Owner BY -- ----- ---------- ---- --------- --------- � Title - t (If'other than owner) .. OR JDEPARTIWEtOT USE ONLY o s APPLICATION ACCEPTED BY ------------` ------.-- ..DATE.------W 7-- ---------------------- / IVISION OF LAND NUMBER-- ---------------------_..:- ----- DATE. _ADDI : -------------------- ADDITIONAL TIONAL COMMENTS----------------- ---------- ---------- - ------------------------------------- -/------- ----- ----- ---------------------- ------- ------ . ---- ------- --------------------------- ------ --- - - - -- -..r._ --- -- -------------------------------------- ------------- -------- - - - ------------------ --- -- ---------------------------------------------------------. ------- ' A ------------------------------ ---- -- Final -Inspection-by-------- ----- ------------- - ----------- ----7---------- ----------: D IL t- EH 13 24 `+SAN JOAQUIN LOCAL`HEALTH DISTRICT F&S 21677 REV. 7176 3M