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FOR OFFICE' USE: APPLICATION FOR SANI714 sEifN11 7 FOR OFFICE USE: -- ------ -I---------------------------------- gg (Complete in d .ycate) I Dli ------- --- ----- L JUL 21 1977 Date Issued__-.2S--17 ------------_---_-------- --------- -------- _ This.Permit Expires 1 Year From Date Issued T— -JOAQWN tfi,CA Application is hereby made'to the San J' a oquin Local Health District for H(p-j mit-to[eo st 'pt, in the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Tulesanhl Regulations: JOB ADDRESS/LOCATION �__.___ __________ - ---------------- --- ------- -: :: CENSUS TRACT Owner's Name '' ------------ ------- --------.: `-� hone.------- ---- --------------------- ---- Address----- --- -- - f -------- - ''4`�` -------- City... ..... ---- .-- Zip Contractor's Name_/Z,4t _._`__ _ License #___ Y _ Phone__.-_.. Installation will serve: Residence ;. Apartment House.❑ Commercial ❑ Trailer Court r Motel ❑ Other----------- ---- --- ----- Number ---Number of living units:____-Z---------Number of bedrooms_____S_Garbage Grinder____-___.-_Lot Size.:12_f_.3 4..... ______..._� Water Supply: Public System and name ------ --------------------------------------------------------------------------------- -----------------n_Nriivate Character of soil-to a depth of.3 feet'. .Sand ❑, :Silt❑v, Clay ❑ � Peat ❑ Sandy Loam D. - Clay Loam-0 t Hardpan/E] Adobe d Fill Material-------------If yes, type-------------------------------- jP18t plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] ^_ 'ANEW INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK [d� Size-- _______________ ----------- ..........Liquid Depth-__ """-."""__ t Capacity_ �,Q.-------Type. ___ "-Material_. - Compartments- __ .- ------------ ' F Distance td nearest.. Well-___"._-2a'_ ___ ------------Foundation.""_-_/__� "_"""".Prop. Line____ - LEACHING LINE, [ No. of Lines.__ - - .........Length of eacF line` - Q . Total Length 'D' Box--___i'----Type Filter MatericiL.____ ,- Depth Filter Material------ r Distance to nearest: WeIL.._- " ] Foundation ---------- .Property Line-; r� ---- ---- -- ---- Water Table lameter__-___ __ Number?.__.__-_ - - Rock Filled Yes No i PAGE PIT [ ] Depth_ a P;. . !` Ji /r th -------- =-' �� Rock Size_. c? ---------------- `-------- ----------------- - -- Distance to nearest: Well.'-__- -_ Pro Line.___ # ��°.1- ----r-��"��Da edation-----��------,&------.Prop, ,-� --:--- �-- REPAIR/ADDITION (Prev. Sanitation Permit#_____________________ ______._. t ----------------------------------.----------- --------------------------------- ] Septic Tank (Specify Requirements)-------------- ------ ---- - -�t - ----- --------`------ DisposalField (Specify Requirements)-------------- - ----- --------------------- ----------------------------------------------------------------- --`-------------------- --------- r -----_-------------------------------------------- ---- -------- ---------------�.L ------------____.___.___.____.____. _"_-___.___ ._ ___.__._ ________________ ____.______.________.____.. _ __.r __ ___.._____________ ' (Draw existing anxa_reguiPed add_ition.on reverse side) 1 hereby certify that.1 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 San Joaquin Local Health District. Home owner or licensed agents } signature certifies the following: "I certify that in the performance of the work for which -this'pefmit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensatiofi laws-�rr-bf;California."" Signed----------------- ----- - ------- Owner 9 B ------ a - --- _ . Title = ' -------------------- ------- (If other than owner) ` FOR-DEPARTMENT'USE ONLY '! APPLICATION ACCEPTED BY-- >/ /1 4' = ---------------------------- -- DIVISION OF LAND NUMBER-------------------"- _-- ------------------------- -------DATE.-- ---------------------------- ADDITIONAL COMMENTS------------------ ----- 4 --------------- �� f ---- --- - - --------------------------------------- ----- - -------------------------------------- j-- - - --------------=-------- 4------ ----- ----------------------------------- -- 'i Final Inspection by----=-------- - -- --------------- --P----------------•------------------------=----- --:Date ------- - --- EH 13 24 SAN JOAQUIN LOCAL HEALTH,DISTRICT F&S 21677 REV. 7/76;