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FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMITFOR OFFICE USE: --'----------------------------------------------------- - Permit No._78-_ (Complete in Triplicate) -------------------------------------------------------- k� ( Date --------------------------------------------------------- This This Permit Expieees•1'Year From Date Issued Application is hereby made to the San Joaquin Local Health District for d permit to construct and install the work herein described. This application is made in compliance with County Or 'nonce No. 549nd existing Rules and Regulations: JOB ADDRESS/LO ION----- ----------------------.CENSUS TRACT. -- '! Owner's Name- 5---------- ------------------------------------------1---- -------------------------Phone--133T.-' , Address- -------------- City._. . --- -- ---------------zip---- Name.--_ 4� ._�'t._C t'�.✓_ ___ ----------- ----License #_._ aS_� ---Phone_,.16-6r--3 3.. .-. Installation will serve: Residence ®//apartment House ❑ Commercial ❑ Trailer Court ❑ I Motel ❑ ' Other. Number of living units:_--. _- _ Garbage Grinder-___ Lot 5ize.___._ 7r��_.. ' ' �_ .__Number�of.bedrooms�. .__.__._Gar.ba - --- ---=--------- - ----------- Water Supply: Public System and name------------------------------------------------------------.-.----------_ ------ - - ---- . - -------------Private Z�__ , Character J,-soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ ' Peat ❑ Sandy Loam�ay Loam ❑ 4 s Hardpan°❑ Adobe❑ Fill Material____-_-----Jf yes, type---------f--------_-----_-----__ , (P;I RIan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on revere side.) NEN INSTALLATION: t(Noy�ptic tank or seepage pit permitted if public sewer is available within' 200 feet i 3 ' PACKAGE TREATMENT [ ] SEPT-IC TANK '[ t Size---__5___X_ _._/ a�Z w,---Liquid Depth A_ s__-----_ T ' e ; .. Capac.ty��1_�JD�-_. -�T Ype-___ ___u�__ atIal2dr_�t"- " No--eomaartments------Z------== ----�-- -------------- unati _ Prop. LnDistance.to nearest: We ----- ------ Fodoe : LEACHING LINE [c�No, of Lines-:-__.---- ---------�___.�._._,___..:;.L`engtFt of,.each line 0. ----.-.---Total Length.___-_A�_�.....__................. D' Box- --_ T e Filter Mater�alf_!__ :--___ ---Depth Filter Material ___.-__r__ ________________________________.i Yp � r Distance to nearest: Well_.._/�_�1__ f _:.---Foundation__ -S_ -' _.____Pro pr` Line... b�_-- ----------- ••�� .. _ ... ... : . r .. _ -' -_ gyp' SEEPAGE PIT [ ] Depth____;___--____.Diameter-;____ Number__.__-_�-----_._%______________ Rock Filled Yes ❑ No ❑ Water Table:Depth ------:---=�`-�--- --- -------- R Size---- - - D s i Foundati F tan�e;ta nearest: We1L`--- ---------------- on----------------------------Prop. Line-------------- .-- -------- REPAIR/ADDITION (Prev. Sanitation Pe'mit'-�#�_.�1__,:Ar:_- -s--:-------- -----.Date-f------------------------------------------1 Septic Tank (Specify Requirements)- - _------------- ---------------------------=----------- -'- - ------------- --=----•-------- r Disposalie (Specify i --------------------------------- - - ------------------------ --- ---- ------------ --- -- ------------------ m and required 1 , ,' - =. --------- -------------------------------------- ------------- ----------------- ------ t (Draw existing a ' q faddition:on reverse side) I hereby certify that I have preFtared this application and that'the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the SanlJoaquin Local Health District, Home owner or licensed agents signature certifies the following: "I iertify that in the performance of thework for.which this permit is issued,'] shall not employ any person in such manner as to become subject to Workman's Compensation .laws of Calif'ir'nia." Signed------- --- ----- ----- -- -- -- i. ---- .:. Owner I- B 4" -------------------- ------------ --------------- Y-- ! (If other than owner) ` = t FOR DEPARTME T USE ONLY APPLICATION ACCEPTED BY = -------------=---------- DATE ------- DIVISION OF LAND NUMBER----------------------------- :-------------- DATE.. ADDITIONALCOMMENTS----------------------------------- --- -------------------------_-------------------------------- -------------------------------------------------- ---- -----=------------ -------------------------- ----- ----- ------ --------------I---------------- ------------------------------------------------------------ -------------------- -- ------------------------------ ---------- ------- ----------------------- ---------------------- ----- Final Inspection b ------- =---------------- ----------Date - L EH 13 24SAN JOAQU LOCAL HEALTH DISTRICT F&S 21577 REV. 7/76 3M