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FOR OFFICE USE: FOR OFFICE USE: G APPLICATION FOR SANITATION PERMIT l ------------- 7 7-oz. a . `� s - (Complete in Triplicate} - '-------------Permit No. ' t_ A - �` / ----��------------ ---- -- ----•------------ Date Issued__- 77 -------------------------------------N ----------.---.-- This Permit Expires 1 Year From Date Issued Application is hereby made fo-th'e•Sari J'oaquiA,eLocal Health,District for a permit to construct and install the work herein described. This application is made in compliance with Co ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -- Ly - # ----- --------- .CENSUS TRACT- Owner's Name._ - u------- ----- --- --= .., -------------- -.: -.---------------------------- -Phone----------------- ------------- Address ---- ----- ---- -------------- - C i License # !_ :_ Phone zip i ---:--------- w _ - Contractor's Name--------- --------------- hff; ------- - e Installation will'serve: Residence � Apartment House ❑ Commercial El Trailer Court ❑ i Y I ;• Mo el ❑ Other------ -- '---------- --- = Number of living units----- ---------Number.of ber +rooms-.-_�Garbcia Grinder--.- .-----_Lot Size___._-- L" Water Supply: Public System and.name--___ -- --- ---------------- -------------------------- .. � - _:-.------------------Private Character of soil to a depth of 3 feet: Sand Silt❑ 'Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam s 'Hardpan 0 : Adobe❑ Till-Material----------- If yes, type------ ----------- - IN (Plot plan, showing size-of-lot-location--of-system-'in relation towells, buildings—etc.must be placed on'reverse side.) NEW INSTALLATION: `(No-'septic-tank -or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] > SEPTIC TANK I`l Size----- __----Liquid Depth.----------------------- ------------ - ] Capacity__- _ ==..._. .T e.-- Material '• -- -=---------No. Compartments - ' YP -- 3 Distanceao nearest: Well-----.i--=-----------',------------ ----`Foundation---------,-_--------.------Prop. Line------_ LEACHING LINE; 1 ; ---------------- .] No, of Lines.-_ ;-_„ --- a_ Len th of each line ` I g , Total Length _. tiD' Box :..--;Type Filter Material__�!_ (Aor/1Depth�F.ilter Material �+ -- Di5 ante o nearest: Well----------------- -lam Foundat ons - _ - -.- - i -- - _�-- , �� --------.Property Line-----,---.5- I [ 1 Depth_o"_1��- iameter------'-----------Number---- ------------------------ Rock 1 filled ' YeS o Water TableM1Depth .��= -----------------.--- Rock Size----- -• �-.E � � ` - - - - i Distance.to nearest:Well-------t, v+-- -------------------Foundation--- ! -------- Prop, Line------ ' �---- ----. REPAIR/ADDITION (Prey;Sanitation Permit#------------ -------------------------------- Date------ ----------------------'-- ----1 r Septic Tank (Specify tRequirements)----------- ---_--.------_-_ '_.____'- cify Requirements) '_ = ----- --------------------= --------- Disposal Field (Spe --------------- ---------------- - ------------------------------------ --------------- ----------------------------- # (Draw existing and required addition ons erse side) " I hereby certify that ( have-prepared this application and that the work will �b done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of, the San Joaquin Local Health District. Home owner or licensed agents f signature certifies the following: I "I testify that in the performance 'of the work for which this permit,is. issued, I shall not employ any person in+such manner as 1 to become subject to Workman's Com ensation lows.of Californ'ia." E E t Signednes BY ---- ---- =--------------- - .. Title r I ]I other than owner ' s ► Ale f t FOR,DEPARTMENT USE ONLY ". . APPLICATION ACCEPTED BY :. ----------------------- --- -- DATE.-. DIVISION OF LAND NUMBER.-- ''fi -------------- F' DATE.,_ = DATE- -= ------------ ---------------------- li ADDITIONAL COMMENTS_._-- '-- -•__-- - - ------------------ ---- ---------- ", l { •-___•---____••-___•- ---------------------------- ------------------•---------- ------------------ ------____----____.---____--____-__.-.. -----------------'-------------------------------'------------------------------------------ '-----_ Fi.nal-Ins Inspection b � P Y £ ,� -------------------------------------- :Date ------------- ' �. EH 13_24s / SAN JOAQUIN LOCAL HEALTH DISTRICT " / F!&S 21677 REV. 7/76- �f y 3M �