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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ --- 1 Permit No. ------------- - [Complete in Triplicate) s77 ------ Date.Issued--6-------------- --------------------------------------------------------- This Permit Expires l 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 e ' ting Rules gpd Regulations: ! r - JOB-ADDRESS/LOCATIO J - - - --- -(ll.e'�_-'--- .,----.CENSUS TRACT.._._--•---------------- Yr, Owner's Name---------- ------ ------_-- -- --- ---- hon Addres 'Ci ,e s --- , - . . ----.---- = Zip------------------------------ y tY Contractor's Name__ �..., R-t_License #-07'C _ _Phone.,//- _��__7 Phone.,//- Installation serve: 1 Residence Apartment House.❑ - "Commercial ❑ Trailer Court ❑ Installa _,._ Motel Other `-------------------------------------------- CA---= -------------------------- >, � .......�..r- .; �,�,�..��-,_-„r„� Number of living,;units:_ Number of bedrooms_r . Garbage Grinder _Lot Size_____'” ----- Water Supply: Public System and"name � ' i 4 ' '` - :: _ _ ._._ _ --..::--Private C, �r Character of.soil to a depth of 3-,feet: Sand ❑,_.Silt Q Clay ❑ Peat ❑ 5andy Loam.❑ Clay Loam ❑ Hardpan ❑ Adob r- Fill Material............If yes, type \1 (Plot plan, showing size. of.lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) , Y _ NEW INSTALLATION: (N-. o septic tank or seepage pit permitted if public s�� is available ,] within 200 feet ' PACKAGE TREATMENT [ ] SEPTIC TANK a Size--_ _____ - JQ------------Liquid Depth.l____ ________ - Capacity j6o-6A Type-�-94¢t�--Material.- No. Compartments--------_;, ------------------ ---- Distance to nearest: Well-'--15-0_ --------------__---______Foundation.-/ __-__.__.___-_Prop. Line--_�--__ ;�----------.Total Length � � LEACHING'LINE � Na. of Lines----- --------------------Length of each line---:---- � e-� -----------------i---.,,----_-.---_-,------ D' Box.._._/.----Type Filter Material__ (4-1 Depth Filter Material---_�� _ _ Distance to nearest: Wel l---- ----------------Foundation----- ___._______.Property Line---`�.,_-------------------- --_ '• E PIT ( Depth__ __D,iameter-_. ..Number___ __ -_ Rock F Yes No SEEPAGE - _ Rock 5ize_.___. ------------------------------------ 0 I Water Table Depth------------- �C-" ^ e -- -- a !'. t + Distance to nearest: Well-..-_. _ ______________________ Foundation_`__��____.:_°_'Prop Line..._ __-_.__.__-___ -- ` RE tic T ADDITION'[Prev. Sanitation Permit#--------- ----- ------------ ------- -----.Date = ]• REPAIR/ -; p Tank (Specify Requirements)-- ----------- -- ----- -=------------- -------------- Disposal Field (Specify Requirements)--------------------- ---------------------------------------------=----------------------------------- ---------------------- ----------- ------- = --------------- ---- t i {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 licensedagents sigAuture certifies the following: "I certify that"in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject-to Workman's Compensation laws of California." i Signed-' _ - Owner Ci-ARENCEIS .SEPT�IrCr�ra& SEWER sW1ElcRSERVICE E- ---- 263 Sc) Oro Stovkto7, Ca'if. 95205 B Title----Ph.-4 3 - -- (If other than _ ..., .- . FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -- ------ -----------; --------------------------------------- --------DATE.-----1.2- --------------- ADDITIONAL COMMENTS = e�` 7 , DIVISION OF LAND NUMBER.-------- - 7 Y ------ - -------- ---------------------------------------------------DATE-Y-- - �f ------ ----------- -----=--------------- __--- --- 7s- ------------------- --- -- -- :---- -- ---------- ------------------------------------- ---- --- -- ------------------ - ---- 7--- --- -- ----- ------------ - . --------- Final Inspection by---=------=---- �I� - -- ---- _ - Date. f - 7 EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M