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FOR OFFICE USE: P G, arc aJ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---t" -----------------------------4444-4444-- - f � i (Complete in Triplicate) Permit No.__.77-__7ry -4444-- --------------4444-- - ----- ---4444-- - _6J� Date Issued. •------ -------------------------- --- ----- 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..7_3-7...... V tA/-----Wv--K 'lam CENSUS TRACT--------------6 Owner's Name _ -_e- _l t-s.p� ------------- --------- ----------------Phone Q �aX d Address r.-:._. ... - ----------city HiQ-�------------------ Zi 4444- - p -l'�---4444-- Contractor's Name_;,iS Y� - - -------------- -- -------------"-------------------- - -License #-------- ----------------Phone Installation will serve Residence)X Apartment House [j Commercial ❑ Trailer Court ❑ Motel ❑ Other---��_,> ._ Number of living units:.-----,_.Number of bedrooms _- ------Garbage Grinder------------Lot Size--4444-- --- -- - 4444-" 4444-- ----------- ---- Water --4444-- Water Supply: Public System and name----------------- ----_- Private 4444 -_-_-4444-- - --•---- -w------------------------------------------ Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay [❑ Peat ❑ Sandy Loam X Clay Loam ❑ Hardpan ❑ Adobe [] Fill Material------------If yes, type------------------------ —"' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage;pit permitted if public sewer is.pvailable within 200 feet,) G !r' PACKAGE TREATMENT [ SEPTIC TANK � :Size----.--(?-, 1 __x-2L- ------Liquid Depth------- v-_44444444- Capacity-t. �'_ 4444 ype.-.- �� Mater ial No. Compartments.------- 1. - --- Distance to nea st: Well------Z-17ZP__ -_ ---------------Foundation..--1 - __ Pro Line.-�.__ ""� f p. ------- LEACH(NG LINE No, of Lines ;L- __.Len Length of each l4Dp4thFilter -_ / - ,.� - gth rZ� � ,.- Total Length.--- _ r ------------------- 1 /Lp: - t/ D' Box_---. __Type Filter Materia l__-----_.�_ Material-----------142-------------------- ----------4444-- -- WIQ� istanc to nearest: Well__.__ -:-C_.Foundation----AU.. — ------.Property Line_ _SEEPAGE PIT Dep [I] "` thy .--_---__-Diameter________________---Number----.______---_--_-----__-,__ i Rock Filled Yes ❑ No Water Table DepthRock"Size:- a --- Distance to nearest: Well---------------------------------------------Foundation-------------------------Prop. Line------------------ REPAIR/ADDITION (Prev. Sanitation Permit#_._._-_---.- n----. __ ------.Date------------------------------- --- --- -- 44 44---4444-1 Septic Tank (Specify Requirements)------- ----- ---,_ ".. a`_ _ ----------------------------------------------------- � Y Disposal Field (Specify Requirements)------------- �-= ------------------------------------ ---- 4444-- ---- ---------------•--- --------------------I-------------- - - ----------------4444-- -- --4444-- --4444-- ----------4444.- -----------------------------------•---------------------------------------------- - -------------------------------------- (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 becomAs - 410011-1, Workman's Co�mf,,ensation laws of California." Signed 101-- /r -Ct----------- --- -------------------Owner By------------------------------- ---------------- ------------------------------------- 3 Gc/ ------ Title------ --d N ~ S S (If other than owner) FOR DEPA ENT USE ONLY APPLICATION ACCEPTED BY -- .... ... DATE.-- ---- ------- ------------- DIVISION OF LAND NUMBER -------------------------- --------------------- --- ---DATE---------------"-- --------4444-- --4444-- --------4444-- ------•4444--4444-- - ADDITIONALCOMMENTS-- ---- --------------------------------------------------------- ----------------------------------------------------------- --- -- ------------------------------ -------------------------------------- ---------------- ---- ------------------------------------------------------------------------------------ - ----------- ----------------- ------- ---------------------------------------------------------------------- ------------------------------------------------------------------------------------------- -------------------------------------- -------------------------------- - ---4444-- !/If --444444 44---4444-- -- 4444-- --- -------------4444-- -------444444 44---4444-- - ---4444-- ---------4444-- -------4444-- Final Inspection by: --------- ------ ---------- ------- ------------ ------------- -------------------------Date.-/ - ---77-- ---------- FN f3 24 SAN JOAQ IN LOCAL HEALTH DISTRICT (_A 21677 REV. 7/76 3M