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''FOR OFFICE USE: FOR OFFICE USE: APPLICATION POR SANITAT{ON PERMIT -.--------------------------------------------------------- Permit No._78_"_-'____ __._ ---------------------- -- -- Date Issued_g=1T= •------------------------ - -- ----- (Complete in Triplicate)------- This Permit Expires 1 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: JOB ADDRESS/LOCATION----- -�'2�-GS-_ G- Ln� 9Z--------- ---------CENSUS TRACT-------------------------------- Owner's Name �- Phone_ —Z�d� ---- -------------------------------- --------------------- ---- Address------------------------- ►t' ------E - � -City -------------Zip------------------------------ } 2 n Contractor's Name_____.___________ _ . _._fir-_T&W-0________________:.License Phone--- _ , Installation will serve: Residence❑ Apartment House.❑ ommerci 1 ❑ Trailer Court E]/ Motel ❑ Other..__�Z _�'�4-s�t.P,_ Number of living units:- 1 ;_r. � Number of bedrooms Grinder------------ ot Size-- Water Supply; Public System and name---- ---- ---- ----- c - ------ --_ -------- -- -------- - ----- -------- -------- ---------Private Charactei of soil to a depth of 3 feet: Sand E] Silt EJ Clay E-] Peat E] Sandy Loam [] Clay Loam , Hardpan ❑ Adobe Fill Material_______: type-; _t;, m_ k:----------- (Plot plan, showing size of bt,16cation of system,in relation to wells, buildings, etc. must be placed on reverse side.) NEIN INSTALLATION: (No septic tank ©r seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK _P� ;- Size__ r --- � K--- ---- ----- - ---------Liquid Depth --------- ------- -----� Capacity-. --------Type--A-0-C-77 -Matdridl'--- �---No. Compartments----------Z'------------------� Distance to nearest: Well______________ _a✓�_ Q--_____ f"_____-Fo?_0 Foundation_______ 0__�-___ _-Prop. Lino_w�_+___ �'________. LEACHING LINE , No. of Lines_._______.l-------________Length f each line--_-____ ___Q__.______._.Total Length._____--l__ _----..________-_______ 'D' Box__________ ___ _ _Type Filter Material___ _______Depth Filter Material____..___-___� ___t----------------------------------------- Cs Distance to nearest: Well___ Q --___Foundation-------�.Q_ -.0- Property Line___ � .____-. SEEPAGE PIT . , Depth__�,___ Diameter____ __ -- _ _ Number__________�-______ --_- ____ �( Rock Filled 'Yes No E]--� t Water Table Depth---------------------------------------------------------Rock Size -1{- -------------------- Distance to nearest: WelL_________Ilel� 'i' +_____-.Prop. Line___ ��-- ----------------------------.Foundation ----lQ------- ..�i-.,------•--------- REPAIR/ADDITION (Prev. Sanitation Permit#. --_.__.________________________.__..Date__.-_________.-_-___________-_.-________- Septic Tank (Specify Requirements)---- -------------------------------------------------------- -- Disposal Field(Specify Requirements)----- -------------- -------------------------------------------------- -- (Draw existing and required addition on 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 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 permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed------------- ------------ --- Owner ---------------------------- BY ---------------------------------------------- Title --------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - - -----------------------------------------------DATE.-A,!/�'_ ----------- DIVISIONOF LAND NUMBER.-------- --- --------------- ----------------- -------------------------------------------- -------DATE-------------------------------- - ADDITIONAL COMMENTS- ------------------------------------------------------------- - ------------------------- -------- -------------------------------------------------------------------- --------------------------- ----------------------------- -------------------------------- ------ e - ----------- -- -- ---------- ------ ---------------------------=------------------------------------------------------- ------------------------------ ---- ---- ------ --- --- - -------------------------------------------------- - _ _ ---------------------- ----------------- Final ------------ Inspection bY:--- ------ ---- - ------------- .................................................Date_ -/ < EH 13 24 SAN OAQUIN LOCAL HEALTH__DISTRICT Fas 21677 REV. 7� �n,