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FOR OFFICE-USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -2 7 � t -------------------- ----- -------------------- (Complete in Triplicate) Permit No.--- --------- -- ----- -------------------------------------- Date Issued_a__ __--_`_- 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 Ordinance No. 549 and existing Rules and Regulations: y JOB ADDRESS/LOCATIO = - = CENSUS TRACT ----------- }} -- ,,1 Phone__.-----`---------- ---------�---- Owner's Namel---------- - - --Q- -- ---.-- ?= C- --------'---------------------------------` ---. - : Address----------------- ----------------- -----" -----'---- --Cit ---ZI -------- Contractor's Name ��' r License #. - Phone--------- Installation will serve: Residence•;!�' Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----- ---- ---------------- - 1 Number,of-living units: ____ _ __Number of bedrooms:._.-__.Garbage Grinder Lot,Size ._____� -. -------- ark _ _�. , _.ter e 11 Water Supply:-Publiic�System and name_ -_---------�?_ ,_!._--..__`_01I-ec_-ea-_ .__ ._ :_5_- _._--------------------------Private ❑ Character of soil to.a depth of.3 feet: Sand ❑ Silt❑ Clay ❑ 1 Peat 0 Sandy Loam E] Clay Loam Elt F :Hardpan :nAdobe'jg 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-) 1 � f NEW INSTALLATION- (No 'pit[No septic tank or seeppermitted if public sewer is available within 200 feet,] , S' .: , PACKAGE TREATMENT [ ] ' SEPTIC TANK`['] S" Size--- ------=------------ =--------------------------------Liquid Depth..:'------------ ----- --- Loxts rrr.Gr Capacity:--- lTYPe--: ° - = Material . . - N.o_. om art.m.Pero,npts.___n:.__: ---- - —t'- --- Line__ -Distance to nearest: Well_ __ ___- -------Foundation_______ # /O[3 LEACHING LINE. No, of Lines--------,.--::------- ' ---Length of each line_ __ 1Ud__�7-�------Total Length--------------------- �-{-------y-C�' C �` 'D' Box----.--_._._7 a Filter Material - �------------- dation-_--er Material-------------------.----------------------------------------- Distance ----------_---- - .-Type _ Depth Filter Distanceto nearest:Well------w�'I_-4'__ Foun �a- _-.Property Line��- � __�-____. _ L,y, SEEPAGE PIT [ I Depth---'-� -:_ �r._lf._ ---- Number----------=------------------ Rock Fi"led , Yes.❑ f No l ! Water Table Depth--- - ---------_-------- --------------------------Rock Size-------= ------------------------------------- -F ---------- --- -- ttiu . Distance'.to'nearest: Well----------------""-----------------=------Foundation._----------_------__ Prop Line _-- -- < r- ' REPAIR/ADDITION (Prev. Sanitation Permit#__°_-_:- ______-__----------- --^Date--_.----.--______- ------ R Septic Tank (Specify Requirements)--------- � f _/ -=--- =-=------------------------------------------------- ---- ----- --: --------- ----- 7 - Disposal Field(Specify Re ulrements]-_._,fW.� ------------------ -- r i --ai - �-�C.S�----- __ ��--------- ------ 1_ Q - ----------- ------------- ------------------- .(D aw existing and required,,aidition.on,reverse_side]_ ,� T --. 3 I hereby--certify that I have prepared this application and t iii-thwork will ;be done, in-�accordanM•withrSanxJoaquin County Ordinances, State Laws, and Rules and Regulations of the' San Joaquin Local Health District, Home owner or licensed agents signat re certifies the Following: Fk "I certify-th 'n the performance of the iwork for-which this permit is, issued;I`ihall not employ any person in.`such manner as f ] to be a ject to..W k . Compensafioa lays ofCalifornia.':' I er Signe �- Com_ ------- -- ---�- s .� y :. --Owner -- 3 Title---- ------=-- -- ---------- --------- BY- -- - _ 4 (If other-than owner} 1 FOR DEPARTMENT-USE ONLY APPLICATION;ACCEPTED BY,._-:'_--'-- _ -G-- `• 1 DATE.--- - ----7=-- -- --- DIVISION OF LAND NUMBER -_--__-_.1_.______._ -------DATE-:------------ i ----- ---------._ ADDITIONAL M E T5 ; - I --------------------- /� _ -------------------- � � f„ - ----- -- ---- --- --------------- ----- ------- Final-inspection 'b ------------------------ -----------------Date -------- 7 F------s--`------ FH 13 24 S N JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M