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.r FOR OFFICE USE: FOR OFFICE USE: i. APPLICATION FOR SANITATION PERMIT -------------------------------- -------- Permit N 77 7' /5 ., ---------- - E ,�'' _ „�, � (Comple#e in Tripl3catel ---------- --- ----- - ` 4 it Issued - �._7 7 ---------------------______ `* -------------------------�I This Permit Expires 1 Year From Date Issued Date ._3_ I! 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 Ordingancg No. 549 and existing Rules and Regulations: 10, JOB ADDRESS/,OC I £N ;_i�-- ` s - CENSUS TRACT - F {{ 2 ( -- Owner'L Name.,------ ----------- --- --- -------- I --Phone--4 € -- ------ - --- d;—L � ' Addres ,��1 ._ .. '�_ - City. Zip s fs.3 �' Contractor's Name-c._ : _ License - �- ---- -- -- -- ----- ----- - � � � Phone e , . Installs ion will serve: € esidence [�RRF,70 Apartment House ❑ Commercial ❑ Trailer Court ❑ I! ' i Motel Q Other ! ; E 5_ ' ` Number of livigUnits: A__ __ ___t_Num -. ber of b oo s-_- .__. ar a Grinder's _ Lot,Size ® - _ Water Supply: Public System and,name jam; --------------------------------------` -------------------------------------------- `"--r- _ Private ❑ Ale Character of soil:to a depth of 3 feet ! Sandi❑ Silt❑ Clay, ❑ 1Peat E)`1 Sandy Loam Clay Loam ❑ �I r- s } Hardpan ❑ Adobe- Fill MateridI_-_._ -----If yes, type--- ------'------t a (Plot plan, showing size of lot, location of system in relation to welts, buildings, etc.Imust be placed on reverse side.) NEW INSTALLATION [No septic tank or seepage it perm'ittej if public sewer is available within 200 feet,) € € € :: I ] _ 11 P PACKAGE TREATMENT [ ] -SEPTIC TANK ,[] .. Size------------------------------- --`___--------------- �] --------- Capacity_--_- apacity -_-, a ------ Type------=---------------Material--------------_::------ Nompartmen� ts---------.--------------.---------- ropeae:to nst:-Well ---------------------------------Foundation.-==--------- -------- -PLn _ --- ----6--- LEACHING LINE ko, of'Lines-------------------------------Length •'; of each line Total -------------- ---------- iD' Box_] Type Filter Material_______;_.___i _.Depth Filter Material________________r_.________y_-___ Distance,to nes er st: Well__________ _ __ _.Foundation_.____.. __Property Line _. . _ 1 r Riameter_--___.--`---------Number-------------------------------- a --------- --------------------- ;Rock Filled Yes ❑ No ❑ SEEPAGE PIT [ ] De th-- i p Rock Size a Water Table De th._. --- E -__-_ - ______ I REPAIR ADDITION PrevDlstance?ta nearest: Well ..____ ; Foundation__:_.____'__. .Prop. Line' y i Date = t tion-Permit-# -_. _:_____ .0 • � k— Septic Tank (Specify Requirements) .-- ,.. -------� ------------- =-------- --. -----=------------- Di s os II Field (Specify Re uirements}___ p P Y �. .. ----------------------------- -------------------------------------------------------------------- -------- ----- - ----- - ------------------ - -----=----------- - --- -- ------ ------ --? ---- -------- ---�-._ -� - f ----- -- ---- - _. i } (Draw exi ing a requi d addition Ton reverse side) t i I hereby certify that I have prepared this application and that theworkwill be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hedit"isftict; Mbme owner or licensedlagents signature certifies the following! r ` 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 cty o„Work s Co .pensdtj_ort,.-I'aws of california..".�� ,rk . . ` Signed--- -- -FC►wne.r ' �-------------Title-----� l ' (If other"than o er] if ;I. fsOR7DEP,dRTMENTUSE ONLY e APPLICATION ACCEPTED„BY_ "-- ------ ----------- - - --- � . .- € . . DATE - � � ? � - ' DIVISION OF LAND NUMBER. ----- ----- - -- -- ------------•--- --- ------------ - --------------------------- ADDITIONAf COMMENTS.....m'..."-?— ------- - DATE - ii e �� rItfi 'i� CCS _. X ----- i/_i- . e ------ -� ice' - ----- -- -- - - ------ --- - --------------- ---- - -- --- — - ---------------------- ------- - -'--------------- 1 ---- ------------------------ -- --------- - Final inspection by i - - -- -----=----- ----- EH 13 24 �I. SAN JOAQUIN LOCALTH DISTRICT F&S 21677 REV. 7/76 3M