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FOR OFFICE USE; APPLICATION FOR R SANITATION PERMIT FOR OFFICE USE: ---- ----- - ---- --------- ---- - -7 (Complete in Triplicate) Permit No77- __T- f_ f------ --- --------- --- ---- --- -- - Date Issued_-1-� `.-7-7 This-Permit Expires 1 Year From Date Issued Application is hereby made J the San Joaquin LocalHealthDistrict for a permit to construct and instal! the work herein des r' This application is made in compliance with County Ordinance No. 549 and existing Rules and,Regulations: c abed. x v - JOB ADDRESS/LO CATION ____ �!u/�h � a - --------- ---- Owner's Name_- / -- . ------ CENSUS TRACT - - Ph Address-------- -- ' - / .--- -- - --� _ one '.: - Cit-- -- -=- Contractor's Name__--_ --__-_rvE f � --------t---- --License #p�_.��---Phone-__`�-- ----- _ Installation will serve: Residence Apartment House.❑ 1. Commercial ❑ Trailer, Court ❑ !L1 Motel ❑ Other--- Number of,livin units:__:- j- J i gI� _Number of be s_ _-+-__- arba e.Grinder ,__Lat..Size_ _-/..z.� _ I > ; \ r ; -------- ---- - ------ ----------------- terWaSupply: Public System.and name___-_ ryl ---:-c.- --------------- ------- -------=----- -- •---=�. - ------- -� -----: :Private [] Character of soil to a depth of 3 feet: Sand [� Sil CId t y❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ ,Hardpan.1 ❑ Adobe : Fill MaterialIf yes, type------------------ _ (Plot plan, showing size of lot,(location of system in relation to•wells, bu ildings,.etc. must be placed on reverse side.) NEW INSTALLATION: (Ni septic tank or seepage :pit percriittedif public sewer is available-within 200 feet,) } PACKAGE TREATMENSEPTIC T f, A,.;.PS;ze...... aterjri alCompartments r ------- ---------- ------- -- Liquid Depth Ca acitY :MNo: Compartments------------------------------------ Distance to.nearest:.Well.'.'t.=,, = Foundation - -----.Prop. Line------------------------- LEACHING LINE [„] No. ofjl_ines .:----:--. Length of each line . _--- --'-: --_- :Total Length-------------- ------------------------ . ...-D' -_:--- - s "� t 4 ----- -- -- r - Type Filter a Mgterial _ ___ Depth Filter Material- -_--_____--- [ ------- -- ---- ( Distance'to nearest: Well_ ___ ._;._._-_.___ _-. Foundation_____---------------- ----- --------Property Li'ne-------- ---------------- PAGE PIT [ ] pi _ Rock Filled Yes No ❑ r EE WaterTable Depthp --------- ---------------------------------------------------De th---------- = - �, � - iameter- ----- ----:- Number- =------=- -- _ p -- -Rock Size;--------- 1------ Distance tonearest: Well--------------- --- - I -- --------- ------Foundation.-------- -------------. Prop, Line REPAIR/ADDITION-(Prev:Sonitd`fft'Permit# _ _________ Date._--- I i Septic Tank (Specify Requirements)!- --------- --------------------�� Disposal Field (Specify Re u' ments)_--._- -----_----_- ----- ------------------------------------ ------------------------------------------------- ---------------------------- --------- - ---------------- --- - -------- ---------------------- ---=------------ t -------------------- 11 ---------- - ------------- -------------------------- �� i (Draw existing and r'equi'red Addition on reverse side) i I hereby certify..that I�l ' prepared-thi3 application avid that the work will be done in accordance with San Joaquin County Ordinances, State 'Laws, and Rules and Regula:tionsr'of eche Sen�Joaquin Local Health Distract, Home owner or licensed agents signature certifies the following- "! certify that in the performance`of the work for which this ermit#is issued I shall not em to an p p_ y y person in.such manner.as to become subject„to Workman s Compensation• laws .of .California.";, k , ; ...� } - .............. - ----- - Own&Sig#ed BY- -- n. i ----- - ------Title_----` If than owner) - FOR DEPARTMENT USE ONLY DIVISION OF LAND NUMBER ' APPLICATION ACCEPTED BY_._.- ---- ----DATE = M - = ---------------------- ADDITIONAL COMMENTS. aP DATE - -----_ i r !I ------ -- ---------------- ------------------------------- 4y- . C`, -f -= ; ----------------------------------------- -------------- -7----------------------------------------------------------------------------------------------------------- --------------------------------- ----- ----- Final Inspection by::__ -- ! ----- ----�M - -_ -,�- -- - �.. 6 - - � - ._.. ---------= ate---�—. - - y EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT - - - F8 � 7 REV. 7/76 3M rl./IU1 t