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FOR OFFICE USE: FOR OFFICE USE: APPCCATI:^N FOR SANITATION PERMIT ----------- ------------------- ___ [Complete in Triplicate] Permit No,.77-_7_.___ --------------------------------------------------------- Date Issued.._-_3- - -�� -------------------------------------------------- P, .--•-------- --- --- -------- -------- - .�c ,i � � From Date Issued This Permit Expires 1 Year Application is hereby made to the San Jaaqum Local� lealth�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 ----------_ ---- --- CENSUS TRACT------------ ------------- � .. j Owner's Name- ---------,: ; ------------------------------- Address ----------------------- -- Phone t 7 . ------- - - Address---------- �d — - -------------------- --- ------ ---------------------City. ---- = ------------------------ZiP ----------------------------- Contractor's Name r� -- ------ - --- ---- -License # - ------------------. Phone ---------------------- r Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ >. ' otel ❑ Other---` ;. t � � � .-------- � . zoo _ �y 1., r I Number of living units:___ `Gar g �/ ._tel-_1_ Number of bedrooms___ _ _ ._ Gar a Grinder_._.________ ot.Size_.__ .__ Water Supply: Public System and name----------- r ..._- --,_---__. -- .,--Private ` Hard an Sand Silt L] Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ P ❑ Character of soil to a depth of 3 feet: Adobe ❑ Fill Material------------If yes, type_____�__________________________ P (Plot plan, showing size of lot, location of system in relation to well's;.buildirigs, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank"or seepage pit perni3itted if public'sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK .X]-i Size----- -,x--1a---,x--fQ----------------------Liquid Depth.'- ------------------ Capacity--/-. U° ='Type'_, .--- ------Material---- _ -- _ -----No. Compartments ;-` Compartments----- -------------- ~Distance.to nearest:,Well. _ - Foundation -__ 0 -----------.Prop. Line--- `--------=--- - LEACHING LINE Na. of Lines-- ___ --_ Length of.each ling--- -----------------Total � Length.:__. _ D' Box_.:_.1_j"_._TyPe Filter 'Material------- __ _Depth' Filter Material____-_ - _____________________________________ ._ - - ..,r T.._ � Distancefio _Barest: 1Ne11�.___`°----- - -- - -------Foundation.--- . --------- ----- Property Line.---------------------------------- SEEPAGE --------------------- --SEEPAGE PIT ] Depth__ Diameter_�__.i_ .. _ ----- ___ Rock Filled Yes' No ❑ .l . »-_ ... _.,.;a•-� . . . ._ ;� Number �� - Water Table:Depth x�a_a = ----- Rock Size- - ' Distancelto nearest. Well__ _ ______.__Foundation__1.0 ------------Prop. Line________________________ REPAIR/ADDITION.(Prev. Sanitation Permit#-----r---;--'------------------------------------Date------ --------------------------------------- Septic Tank (Specify'Requirements) ---------- ------- --- = ------------------------------------ ----- - - ---------------------------------- --------- Disposal Field (Specify Requirements) _ --- --------------------------------------------------- 1 -----------•------------------------------------------------------- ----------- ----------------------------------- -------- ---------------- ---------------- -------------------------------------- - - - = = - ----- ---- -- 4 4 . (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 Regulati ns of the San Jocquin Local Health District, Home owner or licensed agents i signature certifies the following: I "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 subject to Workman's Compensation laws of California." ne Signed -------- - -=-- ---=----�1,'---- f r By - - - - _--- ------------------------------------- her ----- --- _ _Title (I other han own t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - --------------- ! , ` - -- ----�' " - -------------------------------- DATE DIVISION OF LAND NUMBER.::-- - - --- --- - -------------------------- -- DATE.-------------.----_-_:---- - - ADDITIONAL COMMENTS------------------------------- i------------------------------------------------------- --------- ---------------------- . ----- -------------:--- �} ;y = j ------------------- ------------------------------------- ----- - -------------v 7� AN - - --- ---- --------- --- - - = ---- ---------- ----- Final Inspection by::--___-:----_. -_j_ ._ JOA bate r= - ---- --- --- EH 13 24QUIN LOCA EALTH DIS RICT Fas 2164 REV. 3n F