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FUR OFFICE.USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ -- -------------------------- --- -- 77--�cb (Complete in Triplicate) Permit No-------------------- ------- -------------------------------- tr Date issued-.7`...--------- ----------------- _"77 --------------------- -------------------------------- -- This Permit Expires.) 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: ADDRESS/LOCATION _ - 2,.�------ ----------/ �-�------------ '..-.CENSUS,TRACT --------------- JOB Owner's Name.--- - _ -. -- ----------- ---------Phone----` -- ---- ------------------ dress- ------ ---------- # ----- �� 7 = �!!- itY ZIP Ad �1-y __' ca- ..License #-- -�-2.2-y ---Phone------------------ - - -----=---- ntractor's Name---(- ---- ..a- Installation will serve: Residence EyApartment House ❑ Commercial ❑ €Trailer Court-❑ 1 = Motel 0 Other----------=-------------- N d f s Number oflivingunits------ --------Number off-bedrooms--_ .__Garbage Grinder------------Lot Size..- .- - �--- ------x---16% :.. Water Supply: Public System and name...-------� ---- f - ir-L:_ _ -- .----- Private Character of soil to a depth of 3 feet: ,,Sand ❑ 'Silt ❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ i Hardpan [�. Adobe .FFit]-Material-_< --Af yes, type_______......_-.. -------------- {Plot plan, showing size of lot, location of system in relation to.wells buildings, et�must-be placed ori reverse side.) NEW INSTALLATION:' {No,se tic tank or see a e . it permitted if public sewer is"-available within 200 fees) P �� •� PJ P P P + PACKAGE TREATMENT [ ] SEPTIC TANK' Size.J�_. 1ji' X- I Liquid Depth ----------------- ---------- I ....._- _S ' No. Compartments-.: -ii.! Capacity: 6_ Material , - . ___ __---. ------ _ 'Distance.to nearest: Well...................a_, -------------..Foundation. Prop. sine._.. LEACHING LINE' [V No. of Lines----------- --_-----.--- Length of each line--- `�, �_ .Total' Length....-.is o ............. 'D' Box ---....Type Filter Material_---- �-----Depth Filter Material. '-. IT-11------------------------ ; Distance'to nearest: We11 "...s, Q.`}[�'�"y. Foundation _f ��. F .Property Liner SEEPAGE PIT [1�]' r Depth..2. �.¢_-_ Diameter--___ �`--:----Number.. . --- ------- ; : Rock Filled !Yes No /` }. ; ��. Rock Size.-�- =------�--------- -------- ------ ----------------------- i Distance to nearest: Well- ` Water Ta a De t _________________' �bQ -Foundation �� Prop. Line.- ..- . REPAIR/ADDITION {Prev. Sanitation Permit#--------------- --- ---------------------------'-----_.Date-------- .-------_:-7--.___ ---) i is Septic Tank (Specify Requirements) -------- ---- ----- - ------------------------- --- ---=--'=--=---------------- --------------------- _ ---- Disposal Field (Specify Requirements)-_- -------- --- ------------ ------=-------------=-------------•---------------------------=---------- ------------ -------------------------- - ------------------- ------------------------ -- - [ ----------- --- i ii (Draw existing and required addifionaon 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 Sari Joaquin Local_ Health District. Home owner or licensed agents f .......Rego..- _ e signature certifies the following: 1 t t _ "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." r Signed- _ OTwitlener.. 4 By------------------------------------------------------ 4 i I (If other than 'owner) ; FOR-DEPARTMENT USE ONLY - – APPLICATION ACCEPTED.'BY- G -- --- -- - --------------- DATE. - DIVISION OF LAND NUMBER----- ! ------- ------- ---- =-----_----------.:.---------- :-------- ,DATE--------- ----=-- ------------------------- . . . , i ADDITIONAL COMMENTS-- ---- ---' -------------------------------------------- ----- ---------- ----------------------- ......... ---- ------------ - _ -------------------- --- ----- ---- ------------- Final,lns ection•b -- � — ----- ---`-- - Date:: - ----------- -------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 2107 REV. 7/76 3M e'