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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . 77 .S_-- (Complete in Triplicate) Permit No.____ "___- Date Issued._.,�7'_/,'!5-1- 77 .-__-_"__ ___________________---- -.._�- This Permit Expires 1 Year From Date Issued 77 on Applicatiis hereby made to the San Joaquin Local Health Dist'r'ict form-permit=fo=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/LOCAT N-__..----- �___-2Q'� ��"--._ CENSUS TRACT -------------- 805 7' " z Z Owner's Name.: _ ------ ----, -------------Phone-- - --- ---- ---- � --------Address_ ` ._. iP --- - Name– f - w� —Co€tractor's Name- a ' .------__ _-..__- ------- License # �� 31 . -----Phone_ Installation:wilFserve: ��------. .i. Residence ,i� Apartm'enf-House.❑ Commercial ❑ -Trailer Court ❑ s r" Motel'❑- Other �. = Number of living units:__,_ _.__._:fLNumber"of bedrooms_____Garbage Grinder..__------I-Lot-Size,---� _ ---------------- Water Supply: Public System and name_____-c'___>___.._--. _ ❑ ' .. ------------ ---------- P f f :__Private Character of soil to a depth of 3 feet: Sand-❑ :Silt❑ Clay ❑ ` Peat ❑ S dy Loam ❑ Clay Loam µ : . _. a ... ,. .,. .._, . .. _ \ Hardpan❑ Adobe. Fill Materia.l_. ---;-----1f Yes, tYPe----(-----=-------------------- ]M, (Plot plan, showing size of lot location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No� septi an'k ;or seepage }pit permitted)if public sewer i# available within 200 feet,) �� PACKAGE TREATMENT [ ] °'SEPTIC TANK [`;] Size ':_--- : _-__-..__ 's' -___Li Liquid Depth .__ q P -----" Capacity ........ -:Type _ --. Material -- ---- No. Compartments--:----- - --- ,. . Distance to nearest'Well-::-.----^' _______________----------------------------------F.oundatian_.:------------------------Prop. Line _ ------------- •� SN. . - LEACHING LINE; ['l,_.•-No. of Lines ---------1------1.-i_..-.r___:____.__-Length(of each line_ .. ----------------Total- Length -_ __ _--. ------------------------1 _ ' ''D' Box-------- -Type Filter Material-'_' r= ".Depth Filter Material--=-------------=------ ----------- ---I------------ Distance to nearest: Well______ �!--------------------Foundation---- Property Line----------------------- SEEPAGE PIT [ ] Depth----_------------Diameter. ------:------;----Num)jer... ---------------------------__ Rock Filled . Yes ❑ No 0 . _------- ----.--------- -----. -. ----- -- ------------- ------- Woter Table Dept:__- _____ Rock ,Size r Distance to nearest: We11. ------ --------------------Foundation.---_------_.-_-- P , __. ' Prop. L e-- -" 'in REPAIR/ADDITION (Prev:Sanitation Pe # . - Date_ _ _.__ } Septic Tank (Specify Requirements)----- -------- -------------- r --- -------- ----------- --- --- Disposal Field (Specify Requirements) - - `- ` -F-1--- --- - - - ---- ------ - ------- _ = :_ -- + - -j- - --- - fes-- !! ---- . (Draw existind and requli6cl addition on reverse side) I hereby certify that'l 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: 3 I "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 . - rkmon's Com 5ation,la =Califorhia.": F Sign ed5��Ah -----Owner „ . .... t `. .. i EY-'- :------=------'------------- ------=----------=------ -- --- � -------Title-- --- ------ .. . . . (If other then owner) FOR DEPART S - '� -o_ .- �11 DATE J _/ 7�- -----'----------- APPLICATION ACCEPTED.-BY --------------- - --:--------.----------_- _-- --- -.-- DIVISION OF LAND NUMBER---------------------- - -----,---DATE.--- _------------ ------ ADDITIONAL COMMENTS---'--: =--- -=-----------------------------------------------=-------------"---------------------------------------------------- ---------------- ---------------- --- ------------------------=------------- ----------------------------------------------------------------------------- --- --------- ------------------------I--- -------- -------------- ----=-------y-------------------------------------------:--- ---- ------------------------=------------------ ,�------------------ ' ----- - --- ---- ---------------- - ---- --- _ - Final Inspection•b :----------- ...»a.�.-- " `. -� �.�' `t-= ------------- � ------. ----Date - ------- ------- ------ ---- EH 13 24 y SAN JOAQUIN LOCAL HEALTH ID ICT F&s 21677 REV/