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FOR OFFICE USE: FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT ------------------------ -------------------------- 77- 3.S' (Complete in Triplicate) Permit No.___________________ ------•-- ---- _ '/ Date Issued_.`✓_1"e_77 - _+ This Permit Expires 1 Year From Date Issued 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ �� _____. __',g v 1, -��@---- CENSUS.TRACT______ l� - Owner's Name--------- -� L,--------- --- 1 -- --- ---- --- ------=- ............. --------------------------Phone--------------------------------------- - Tv----Address � ---- -------------------------------------------- Y _NT � p �� - A --- -- {- ---Phone------- Cit �' � �---- - ------ -------------- e - ---------. �r Contractor s Name-----A,_4-_1•__Chd_�_ �- ------ ----------------------------------------License #�7�� ' . _ i Installation will; serve: Residence( Apartment House.❑ Commercial ❑ Trailer Court❑ i. . Mot 11 ❑, Other--------- --------------- N ---------- -- Nmber of living units:_ 1_________Number,of bedirooms____Garbage Grinder-__- _.__Lot Size. --_ ._.-_; - --- ---------------- u' Water Supply: Public System and name-------- -- di ----'-------------------------`------------------------- -.------I-------------- ----------------------Private Q �- Character of soil to a depth of 3 feet: ` Sand ❑C Silt❑ Clay ❑ Peat❑ Sandy Loam V Clay Loam ❑ ) Hardpan ❑ Adobe i Fill Material_---------If yes,type________________________ ------- .(Plot ______.(Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc. must be placed on reverse side.) a NEW INSTALLATION: -(No"septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ['] ' SEPTIC TANK [ ] - - -,___Liquid Depth._ 0:7------------- pacitY �tl -----Type C®�fiS' aterial =' No. ®ompartments; fX . . _. ---------- Distance to nearest: Well.,.__ _.. _Foundation g.________-Prop Line_ f_ . .__ LEACHING LINE'r�',[ ] INa4of Lines_-_ ,�_-- I __.Length of each line -- -�------ _____Total, Length.___ �P/- -----------------� I i [ •'` D ;Box .._____Type Filter Material/A _-Depth Filter Material____ - -- -------------------- --- Dstanceto --- - nearest: Well --__ __ ____Foundation__ Property Line ____ SEEPAGE PIT [� ] Dispth________________Diameter____-_____--_:..._Number___=__-___'_________._-________ Rock Filled Yes.❑ No r Water Table.Depth------I------- ------------ -.--- -_ --Rock Siz --------------�_---: ---- --- Distance to nearest: Weill-`__ _` _ "______-Foundation ______ _______.Prop. Line---------------------------12 REPAIR/ADDI'6 (Prev. Sanitation Permit#_ � _=___ r -__ _:__.Date _______. __ _____ ___________) Septic Tank`(Specify Requirements) — --------------------------------- -__ ----- ------- ----- ---- ------- --- Disposal Field+(Specify Requir�nents)..� _.a-F-_ . -- ---- -- --------- II -- - - -- -- --- - --------- ---- --------------------- ------ - ---'- ---- - -------------------- . 1 ' 4:_ 1f - ------------------- - -- ------ - --- ---- -- -- -- --- ------ ----- ------- ----- - ' (Draw existing and required addition'on reverse side) t I hereby certify that I have prepa ed tli s;application and that the work will be done in accordance with San Joaquin -County Ordinances Sfat Laws;torr Rules_and Regulations of the, San Joaquin Local Health District: Home owner or licensed agents signature certifies the following. f "I certify that in the�per--formfnce of'1fie wor or which fhis per irm sis� sued;I shall not employ any person in such manner as t ; I 1 „ `� to become subject toy or an s Compensatfonlaof California. Signed I s V ------- ---- ------- ----- #OWner.. ` By-J -- ---------------------------------t--------------------------- --------------------------------!_Title- ------ ------------------------------------------------------_ (if other than owner) r' i 'FOR'DqPARTMENT USE ONLY- F APPttC~ATION—ACCE'PTED--BY--- -------------" DATA ""' __ -7 7 - 1 DIVISION OF LAND NUMBER.__ ____ 11 ____ -� 4. _ .._ � _ t �+ --_.-DATE _ ADDITIONAL COMMENTS-----------------------------------I------ ----- ---- -------- ----- ------------ z ,. _ ��----•".'" "--- --- ------------=--------------------------------------- ------ ---------I- ------ - -------------------- -------------------------------------------------------------------------- I ----------- ---------------------- ---- ---- Final-Inspection by:. Date- EH 13 z4 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M �I