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FOR OFFICE USE. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No -- Sk3� ------- ---------- - ---------------------- [Complete in Triplicate) - ` -------- Date Issued_.�.a'7-77 ------------------------_- This Permit Expires 1 Year From Date Issued ------- O i ! ApplicationUhereby made to the San Joaquin Local Health District for of to construct and install the work herein described. q This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I L 2 U ��.L 05 e,,,, f ------------.CENSUS TRACT--. JOB ADDRESS/LOCATION---------------------------- ------ ------------/- -----f----------------- - - Owner's Na 17.1 }�N1t �1P.(t LFfS�Ce �/ - Phone----��_� --- �� U , L -- w --- 1 is ----- Cit nrlec`-------------------Zip-------------------------- E? -------------------- r Address--------- --.------ ----- f Y---- - - -- y t G� Contractor s Name. ';1�'j C:�l l� - �- ----- ----=---------------- License # X1318 -Phone -.- - - Contractor Installation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ _ s ..:.. 11 atel" t er------------- -------- <, 4 : 1 Number of living units:----------?------Number of. edrooms_. ._.Garbage GrindeYS._.----- --Lot 5iz �2 � - eT -` .. Water Supply: Public System and name-------- ------------------------- ---- ai--- ----- --------- - -------- -.--.-,-Private . it to a depth of 3 feet: Sand Silt Cla ❑ Peat❑ Sandy m ❑ Clay Loam ❑ Character of so p ❑ Y, , Hardpan ❑ • Adobe ❑ Fill Material-------------If yes, type..-.--_.... .__-I-------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings; etc. must belated on reverse side.) NEW INSTALLATION: '(No`septic tank or"seepage pit permitted if public sewer is availatj5jle withinl20 feet,) q I t C7,�C -- I ---------Li u.1d `e th. �i PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----.-_ ___......................... . .. cl / p Capacitys : Material--- NCompartments - : F G Type - Ot` ti t n...._ - ro ..Line3UDistance'to nearest: W ----------------- --- ---Fonda LEACHING LINE. [r]' No. of Lines-,.--.,....�-------------Length of each line,..--.� r----- _Total Length .- __:__.l_ 0--- --- G V ej r r �r ' Box--J...:--Type Filter Material----l-_jZ_'___- Depth Filter Material.-----+-_-- ------.------------------------------------------- { UtJ{ .! t.; 4{. - c. nDistance_to nearest: Well--------------------�.- --Foundation----------------------------Property Line------------------------- _ ..f d' :____-__ Rock Filled Yes ❑ No E]` SEEPAGE PIT [ ] bepth --------------- _._.Number-------------- ---- # Water Table.Depth------------------------------------------------------ Rock Size------------------------------------------------ Distance to nearest: Well- ---------------------------------- -----Foundation-------------------------.Prop. Line------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ----------------Date------------- ---------------------------- ) Septic Tank (Specify Requirements)_--.---- -•---- ---------- ----=-------------------------=----- - Disposal Field (Specify,.'.R --- ----------------------- --------- ', + J eguirementsl_----�---- ---�------. - ,.. ----=----------------------- -- ------------------------= - - --------- - -- --------- ' ------ -------=--------- -- --- -------- ] .:_ ----------------- ----------------------- ---------- ------------------------------------ .. --=---------- ----------------------------------- ----=------=- = = (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 Sig nature certifies the following: k`,1,V,-, c)A R�S-S "I certify that in the performance of the work for which this permit is issued, I shall n employ any person�7n such manner as to become subject to Workman's .Compe sation laws of California." pj Signed. .---- -----Owner ---- C s 3 [ gY L'1^!ti (�-'A1e Cif ------- ------------ 6 ------ -- ------------ Tit1e-------- (if other than wrier) FOR DEPARTMENT USE ONLY -- - ' �v..DATE --- --- ---- ---------- APPLICATlON ACCEPTED BY- :. - -------- I DIVISION OF LAND NUMBER----------------- ---- --•-----•-. - --------.DATE.--------------- --------------------------= ADDITIONALCOMMENTS--------- ---- ----- -------------------------- ----------------- ------------ ------------- ------------------- ------------------------------- ---------- - --------------------- s --------------------------- --------------------------------- --------------- -------- ------ ---------------------------------------------------------------------------------- -------- Final Inspection by:.----.. .._. ------------- -------- ---------------------'A---- -------------------=- -------Date J �r� '== EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7/76 3M