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h FOR OFFICE USE: FOR-OFFICE USE: /L-- APPLICATION FOR SANITATION PERMIT ------- -- -------- pp.�� (Complete in Triplicate) Permit No..�_7-`�07 S --------------------------------------------------------- '� Date Issued //--/O-/77 --------------------------------------------------------- This Permit Expires I Year From Date''Issued ,F 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:4, µ _ _ JOB ADDRESS/LOCATI N-- / 71-� ----- G �� ---.CENSUS TRACT. - ,,ff �^ - ------------- --.-----F" - -/ "`'�� - Owner's Name --- - - -------- -- - --- C�C.�+wr+,.� ----- -- Phone-------------------------------------- Address-- --------------- ----- --------------- Address =- _ol------- -- `l^ .--- City Zip i Contractor's Name_______________ `� '� ----- --- ------License #_- Phone Installation will serve: Residence Et Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ------------ - . --------------------- Number of living units:__.'.:.,__------Number of bedrooms-__-----Garbage Grinder---- -------Lot Size-------G`= "' " ^'.'" %_:__-____-:___--._-__----- Water Supply: Public System and name-- ------------------ ------------ ------------- ---------------- .- ---------------,------------------=--Private [1�/ I Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sand,y Loam e Clay Loam ❑ •Hardpan ❑ " Adobe ❑ Fill Material-- .-If yes, type-.__-____.__-___._____-__-__ [Plot plan, showing size of lot, locafion of system in relation toywells, buildings, etc. must be placed on reverse side.] NEW INSTALLATION: (No septic tank or seepage pit-1permift-ed if public sewer is available within 200 feet,) _ PACKAGE TREATMENT [ ]" SEPTIC` TANK [ Size�_s__-_ -QP--`- --��-- t4`- --------------Liquid Depfih_.-_.-__.__________--___ i Capacity....�aoQ------Type__ .44 Material.---- --_.No. Compartments------a-------- --------"-- Foundat.ion::f___��-�__: � Distance to nearest: Well-..-------. `l)-- -------Prop. Line--- -----------------0 LEACHING LINE [ No, of Lines----------;.,___ --.Length of each line.--------- -_:____Totdl Length .___.___________-__ F ' 'D' Box----1------Type Filter Material--__-_ -----Depth —___-_______ -.._ Distance to nearest: Well.------ Z- -----------"Foundation-=-------- --- ---:Property time SEEPAGE PIT [ ] Depth------------_----Diameter.-------------------_Number---:.____:__.____ _____________ Rock Filled Yes ❑ No ❑ "Water Table Depth--------------------=-----------=------------------- ---k Rock Size----------------------------------- ------------ Distance to nearest: Well--------; -----------------Foundation.---------------:---------Prop. Line------------------------- - REPAIR/ADDITION (Prev. Sanitation Permit#-- ------ '--------::`----------'-----------Date----------------------------------------------] ` Septic Tank (Specify Requirements)------------------ __--------- _' - DisposalField (Specify Requirements)-- ----- ---------- - ----------------------------------------------------------- -------=------------- ------------- - -----------------------.---- t 4. ' ------- --------------------- -----------�--�------------------------= `-------------------------------------------- ----------- (Draw existing and required addition'on reverse side) I hereby certify that'll 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: j "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.Workman's Com ensatio++ laws of California." . T a Si -' - = Owner 9 i By- ------------------------------------------------ -'' ,Title � � (If other than owner) t k 4 R"DEPARTMENT USE ONLY �} ' APPLICATION ACCEPTED: BY-' --------------------------------------------- ---DATE.--,( 3P. -i"----- -- ---------- DIVISION OF LAND NUMBER._-____ ____________ ___ _ ___ ' DATE---- ---------------------------- --- ---------- -----ADDITIONAL COMMENTS----------------- ------------ ------------- -------- ---- ------------------------------------- --------------------------------------------------- k -----'------------- - - ------------------------------ -------------------------------------- ------------------ -__________________________I-_.______.____ _ - _ ` _ inspection by:----------- C'` - - -- ------ =-------------------------------------------- ---Date_ '---- a ANiJOA UIN LOCAL HEALTH DISTRICT Fes zierr Rev 7/76 ann 1 � s `�