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FOR OFFICE USE: FOR OFFICE= USE: 14, _0 APPLICATION FOR SANITATION6PERMI'V tL - Permit No--- (Complete in Triplicate) Date Issued_A5�7/"-77 ------------------ _. 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 Ord•in ce No. 549 and existing Rules and Regulation: ---------- ------.CENSUS TRACT - ---- JOB ADDRESS/.LOCATIC N. - -- --- ----- --------- Ph -- ------------------- ' Owner's Name- - � -- -_ tom` - -------- ------ ------------------ ----- ------- ---- -------- Pt Zip p Address - uu - - � ne � f ---------- License # g�F h o t Contractor's Name. Installation will serve: Residence ❑ Apartment House.E Commercial [ —Trailer, ❑ ` Motel ❑ Other---------- ----------------- ----------- 4• j -_--Lot..Size.---/- .7` � - = Number of living units__ ____________ _ i ` ", " Number of bedrooms e Grinder-_t'• X Private P {!N i Water Supply:.Public System and name ____-_-,.��- i ;• Character of soil to a depth of 3 feet. Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam:❑ :Clay Loam . . s Hardpan ❑ � Adobe ❑ Fit! Material_..._.'_- -_If yes, type---=----------- ' r (Plot plan, showing size of lot, location of.system in relation to wells, buildings etc. must be placed on reverse side.} ewer is available within 200 feet,) NEW INSTALLATION: (No septic tank ;Or seepage pit permitted if public st a y + ` Size__ /t_ s , � 1 r. Liquid Depth TREATMENT '[ ] SEPTIC TANK !] ----------------- PACKAGE -- -- r, ______.- _Materia!___ No. Compartments_ i Capacity_ --o�{u- ------Typel , Q j t --- ---Foundation __3__-A- Pro Line. G : Distance to nearest: Well. , Length of each Total Length.__ "" ----- - LEACHIN LINE �Ci No. of Lines _.::1. 9Qi x ''_ --_----------- i Depth Filter Material---- - ; k . D' Box--------- ,.Type Filter Material_.___ I? r. i f " -_--Foundation-- '_�j Property Line_ �} ----- to nearest: Well__. ---- - .�-tom-_____-,__-t�-- - i Distance Rock Filled Yes No ❑ r T i Depth- , ameter ---3-5 ------Number_ 7 { s l,T t Water Ta61e; eptly--------- ------- - Fou .� P-- i f Rock Size- -- �� op. Line------ ----- Disfance to nearest: Well-------------------------------------------Fo I -Date------ ------------=-------------'------' REPAIR/ADDITION (Prev:Sanitation Permit _--"---------------------------------------------- Septic Tank (Specify Requirements)---- ----------------------------------------- -- -------------= ---=--- ------------------------------ -------------------- -------------------- ------------ -------- Disposa{ Field (Specify Requirements)--------------------- ------ - - - _ -------------------------- ------ -- ------ - --- --------------------- -------------------------------------. -------------- - - =- --- -------------------------------------- -------------------- - ----- -- --------------- ------------- -- ---- :- -- --------- j (Draw existing and required addition on reverse side) ; { I hereby certify that 1 have prepared this application and that therwork 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: sissued, i; r t (1 shall not employ any p erson in such manner as i "1 certify that in the performance of the work for which this permit i to become subject to Workman's Cornpensation .laws of .California." I. - `-.-.-Owner Signed -- i -- _--- ---------- b--------- -------Title I ------- ------------ - Tit e By--------- s (I other than owner) OR DEPARTMEN ''ISE ONLY` f .,--- ------------------------------DATE.------ APPLICATkQN ACCEPTED BY-------- - ---' ---- -------- ----- ------------- -------------- " DATE..------- �`-' � - -- - ` DIVISION OF LAND NUMBER = s . " ------------------ ---- -------------------------- ----------- -------- --- ADDITIONAL COMMENTS a-. 3 =--- i ' _ ___.-__ ______________ - _____________________________ ______._____.____-__-_ - ________________________ __________________________ _____________________________________________________ _-._____---__________-_ ____---_-______--__--___-_-___----------------------------- ._.__ .____._.______-__-____--______. . . ------- --Date.-_�-`� - -- ------ Final Inspection-by::- . --.- -- ' F&5 21677 REV. 7176 3M EH 13 24 SAN JOAqU,IN 1,47CAL HEALTH DISTRICT