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r � � FOR OFFICE USE: FOR OFFICE USE'. APPLICATION FOR SANITATION PERMIT ------------------------------------- Permit No.77� `5� r . [Complete in Triplicate) " r - ::�..� - .."`. . Date Issued- 3 _7- This Permit Expires 1 Year From D_ate`IssV6i!—•�� Y Application is hereby made to the San Joaquir4 LocoLHealth-D.istrict for a-permit to construct and install the wor.k,herein described. This application is made in compliance with County Ord' ante No. 549 and existing Rules nd Reg ions: JOB ADDRESS/LOCATIO .[: ,- - - - - - - `----- -----,-•-----•--.CENSUS TRACT_ ►e-. Owner's Name . Phone----- -6y, Qf -- - ----------- - C� ------ _Zi I Address ----- --------- - - - � � �� - --- ^' -�-��--- -- - . - P-- =---- C ` -- -- - ...-, ---- --.._License #_ ��_,7`�__Phone_ ,��Q� ontractors Name------ ----�---------�-- ----------- --- -------- Installation will' serve: �, Residence Apartment House.ECommercial ❑ Trailer Court # t Motel E] Other = { ff --- ------- .s ms_.._ Garbo a Grinder_.__._.____.LotSize_. .-. --Number of living unts:__`_f.__.__ _.Number of bedroo 1 - Water Supply: Public System-and name------------------ ------ ------ r—--------------------------- _ : .-., ---------------------------Private Character of soil to depth of 3 feet: Sand ❑ Silt❑ 'Clay ❑ ' Peat ❑ Sandy Loam ❑ Clay Loam ❑ t ` Hardpan Adobe Fill Material---- ------If yes, type------------------------=-------(Plot,plan,_howing size of lot-ilocation of system in relation to'wells, buildings, etc'rh6st be placed on reverse-side.) � NEW INSTALLATION:'' (No septic"tank or seepage pit permitted if P'Olic sewer i!,,ovailable within 2bo feet,] PACKAGE TREATMENT [ ] ' SEPTIC TANK ' +' ize._"- _-_ -___p. _ .._..............'Liquid Depth.___ + 4 - a Capacity.t.2 __ --r ype- Maul_ _ . -No. Compartments------- ---------- _.-- , `. _Distanceao nearestFoundation : f - --------------- � IN . . s �`___...._ Prop. Line /Q___. � of -. eng of ea- ine th----.- -______ ____LEACHING LINE, Total rDBox . ----.Type FilterMateri =- De th Filteraterial- - --------------------------------------- ---- tW � nProperty Line----_- t- e ' _ esDisaaton- ' SEEPAGE PIT Depth�_S-_'Diameter-= .---Number--_------"---__ .` Rock Filled Yes No E]Water Table:Depth-/_ - '�'--------- ------ -_.Rock Size`s------------- --t------ 3 D'rstance.to nearest:Well _�_�!__ _r_.__- -------------.;Foundation} =_l4p__r ------ Prop. Line__ ._______+_ REPAIR/ADDITION {Prey. Sanitation Permit-#-` -------------------------------- ------- -------- - ------------] =--==_-- --__- =-. Septic Tank {Specify Requirement`s) = = ----------------- DispoDisposal sal Field (Specify{Requirements): ----*`----`--------'-------------- ---- ----;- = , -• f - v f .. 1. i `� y�' (prow ezisting'and`required addition on reverse side] 1 :r; - I hereby certify thatl have,prepared this application a6 fliat.the work will be done in accordance with San Joaquin County Ordinances,, State Laws, 'and Rules and Regulationsk a,4he San Joaquin Local Health Wstrict,,Home owner or licensed agents signature certifies the following: "1 certify that in the p ormance.of. the work ffor which this permit'is,issued, I shall not employ any rson in such manner'as to becom. ubl t.to. kman-s ompensat' •laws F. California._ Signed-- !✓ 4 -- n '�" . - - e F yr � `- . BY------------------ -- ` --_= ------------------------- --- ----------- -- - --�te -- - -- -- --- --------------------------------- - -- --- -----------------.:----: _ _. , r 4 'FOR DEPARTMENT USE"ONLY .a APPLICATION ACCEPTED BY= ---------------------------------------=------ F ----DATE -----------------------------i- DIVISION ------------------- i- DIVISION OF LAND NUMBER -------------- DATE _ ADDITIONALCOMMENTS ------------------------------------------------ ---------- ----------------------------------- -------- --------------------------------------------------------------- ------"-----------------------------------------------------------------------------------------------------------------------------------------------------------------•- -------------------------------- ---------------------------------=----------------------------------- ------------------------------------------ ---------------------------------------------------------------------- --- -- •--------------------- ------------------- ----------------------------- s Final Inspection by _ _�'� ----------------------` -------- - ----Date -,Vf- --- = ` EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M 4.