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FOR OFFICE USE: "' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------- ------- ----- ---- 6� (Complete in Triplicate) Permit No.__7Date Issued.- 0_a.-".77 ------------__----___ _____-----____________------------- 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION-- v�_!o c�T�------ C /�- - CENSUS TRACT. --- Owner's Name. ----------------------------- ---------------------------- ----- -------- ------------.Phone-- Address. Q 0 77___)W �SS-d-� .. ` C zip--- ---- ----- ---- ----- ----- __ City I/ ------------ - Contractor's Name----- - ...a,-,/.....--------------- ------------------------------------------License #.----....- -- ---- Installation will serve: Residence ❑ Apartment Hou'se-0 C9mmercial ❑ Trailer Court ❑ Z _ MotelNumber of living units------ ------Number of bedrooms___2--Garbage Grinder-----_...---Lot Size.__ .... .......... _.............. 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---------------- --------------- (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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ISize----------------------------------------------------.--------Liquid Depth-- --- ------------------- Capacity---------------------Type.----------------------Material------------- - -.Capacity---------------------Type.----------------------Material------------- ------------No. Compartments.----------------------------------6 Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line---------------------------5 LEACHING LINE [ ] No. of Lines.............................Length of each line-------------------------------Total Length ---- ---------------__--------.-------S 'D' Box............Type Filter Material--------------------Depth Filter Material-------------------.------------------------------------------_N Distance•to nearest: Well-w------------------------Foundation-:----------------------------Property Line---------- ------------------------3 SEEPAGE.PIT [ ] Depth-----.- Diameter. ..Number________ _______________________ Rock Filled Yes E] No ❑ Water Table Depth------------------------ --- ---------- Rock Size.------ C Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line..---------------------------------------ts REPAIR/ADDITION (Prev. Sanitation Permit#___________________________.._...-----------------Date-. ______._____..______...------ ••t' Septic Tank (Specify Requirements).----__. --------------- Disposal Field (Specify Requirements)--_ .(..- -- -- ----C? ------4rtw ----. 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 's bject to Workman's Compensation laws of California." Signed- n,. ----\..Y. r -----------------------------Owner BY-------------------------------------------------- - --------- - --Title- - ---- -----------I- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --------------DATE -- ----- -- -. =?]-- ---------- --- - --- --- --------- --- --------------------- - --------- DIVISION OF LAND NUMBER... ---------- ------------------------------------------------------ -DATE.------- ................ ADDITIONALCOMMENTS--------------------------------------------------------------- ------------------------------------------------------------------------ -------------------------------- -------------------------------------------------------------------------------------------------------------------------\------------ ------------------------------ ----------------------------------- --- - ----- ---- - -------- --- Final Inspection by:------ -- �� ------ r 'L..-� 1---------------------------Date---ee_v_ •-31-----77---------- EH 13 24 SAN JOAQUIN LOCAL HEALTHJDISTRICT F85 21677 REV. 7176 3M