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A FOR OFFICE USE. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No________ _____-------- Date ____ _Date IssuedZb',�_,j-'77 ---------------------------------------------------� This Permit Expires I Year From Date Issued Ap. a ion is ere y made to the an Joaquin Local Health` District for a permit to construct and install the work herein described. This application de in compliance with County Ordinance No. 549 and existing Rules and R gulations: I ......f 0 JOB ADDRESS/L ATION _ ._ r � �� l i� � w CSL 5EN US TRACT Owrfer� Name. Irt� - - � ^-. :----.;.-------------------Phone /...=--� r----- --- _. r.... Address- --------- t,.-Q-- --- -- --� .---- - City- ----- ---------zip--.----- ------------------ Contractor's Name--- ---- - ---� _.-- License # S.K. `--Phone -------- - ------- 4 -.4 �. Installation will serve: I Residence ❑ Apartment House Commercial ❑ Tr •ler Court ❑ Number of living units Number of.bedrooms------------Garbage Grinder-:----------Lot,Size----=-_ --. - ___._.___._. Water Supply: Public System and name--------------------------------- ---------------------------.----- :_ ---.-_-- '_ Private EP?`' Character of soil.to a depth of 3 feet: Sand El Silt E] Clay ❑ Peat ❑ Sandy Loam ❑ Lain ❑ . . r . Hardpan 0 Adobe ❑ Fill Material___-- -If yes, type (Plot plan, showing size of lot, allocation of system in relation to wells, buildingsl, etc, must be placed on revehse side.) NEW INSTALLATION: (No septic tank'or seepage 'pit per"kted if public sewer is available within 200 fe\et,) PACKAGE TREATMENT [ ] SEPTIC TANK * Size=_T��1�--- ° _-___-_s__.______Liquid Depth - 05-- il 9 � Capacity. -- __ _ Typ ___..". .._.__ `-_ a�ial Foundation. No Compartments ? -._-- �/ Distance.to nearest: Well ..__ 1 -_ - �' ` ' _ -- _ _.Prop. Line r :y I Len thrrof eachrl.inr. o e�------- ----metal Length.__Z� �f- . LEACHING LINE No. ofLines_' � ) i ;______;_.,____- � ` j--'t--,Depth th filter Material-'--------------- ----C3 f 1 i � `D' Box------ .__.Type Filter Material ____�-_--_ p I Distance to nearest: Well________________ . Foundation __.-_-.__---_ _.__.Property Line------------------------------------- .1 .. R ..-.- Y� 4+` - a y- p , er =- Rock Filled �Yes ❑ No❑. SEEPAGE PIT [ ] De th ! _- .- Diameter � ,Num i Water Table: Depth- ` `=.;.Rock Size M - Distance to riedrest:'Wel]__.___________________ ___________________Foundation--------_----------------.Prop. Line ---------------------- REPAIR/ADDITION]Prev. Sanitation Permit#___ ---_----_----_ __ _`- __-----------Date--------- -___~" -•_----------------_.-.----) f� Let SepticTank (Specify Requirements)----------=----- ---------------------------- ---- ---------------- == ==----------------------------------- --------- T Disposal Field (Specify Requirements)------- ------ ---- -------------------------------------------.._---_ ----------------------------------- -= . t ) 1? ! -----=----------------------- ------ --------- ----- ---- --- ------------- --- -- - --- --------------- --- ------- it r r (Draw existing'and required addition on reverse side) " .. ._n .... r• A e I hereby certify that I have prepared this applicatiorf�und that.the work will be done in accordance with San Joaquin County Ordinances, State Laws, anda�Rules and Regulations, of•the. San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: r i "I certify-that in th performance of the'work for which this permit{isoissued, 'l shall not employ any person in such manner as to become subject. o Warkman s Co ensation I w5e of California. n t t(� t r- c l _Otivrngr- Signed----- -a----- ---R-'-tom =----- 4 _ _ —"��• BY : :::: ------- -----------�-- --- - .",`Title .. _ (If other" than own..)--' FOR DEP TMENT USE ONLY` 00 APPLICATION ACCEPTED. BY-,> t� .......... =-- ------- - -- DATE�d.:-_ ��----------------- DIVISION - -------------- DIVISION OF LAND NUMBER.- -------------:--;------:--------------------:--.------------------------ ------DATE ------------------------------------------- _T ---------------- ------------------------� i ADDITIONAL COMMENTS__.___ _[__ - I� '� - - ---.---- - - iY _ --------------------------------------- ---------- --------------------- -- ------- --- - ------ -------------------------- ---- - ----------------------------------- ----------------- ---- ----------------- - -- Final Inspection bY:_.:--------------- . .. �. --- � ----------------- -------- _--- --- � -------------------------------- ---------- - - --Date - EH 13 24 I SAN JO QUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7176 3M