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y FOR OFFICE USE: FOR bFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit NoT74V_&_-.__ -------------------------------- ----------- ------------ "•-••••••-----•----••-----•---- ----- ..-.-•�-•-------- This Permit Expires 1 Year From Date issued Date Issued..V. 'p_'79 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/LOCATI N._.----I.7Cp _-.-C.._ C;-Dui CENSUS TRACT. - ...... -- ------ ---------------- •-- .............. Owner's Name..- -. ---- -- -• _--- Phone. Address----- ._ zip Contractor's Name---._ Lice nse # Phone = Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_........ Number of living units:.-- /.._-_-_Number of bedroom s..S j Go2;: G _-___-_..._Lot Size_______________ __ -- . . . Water Supply: Public System and name__ -� - dnder- ______________Private ❑ Character of soil•to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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 available within 200 feet,} r r '� PACKAGE TREATMENT [ j SEPTIC TANK ( Size.- ---. ---- _+ n. 2_�.------------....-....Liquid Depth.-III..- Capocity..1.9W --------Type_13b,'k---........Moterial__ .........No. Compartments...---` .--•-----..... ._ �} ----- 1 Distance to nearest: Well--------A11A•--- --.-_----.--_ -_-Foundation--_-Gt 1. --...........Prop. Line---/I------------- --! LEACHING LINE [ ] No. of Lines - --- ------------ -----Length of each line ---------------Total Length .. ...x:7.0............--...... .� 'D' Box-�_ . ..Type Filter Material-%*._,A� __ Depth Filter Material------18-w--.--------------------------------•----_•_-. Distance to nearest: Well__.Al/�:..............Foundation---0-lP___-____-_---_---Property Line_.._!6-__--__---____-...--_... SEEPAGE PIT [ ] Depth........- Diameter______________..-__.Number-------------------.____.______ Rock Filled Yes ❑ No❑ WaterTable Depth----------------------------- ---------------------------Rock Size.---- ---------------------------- Distance to nearest: Well-------------------------------.--_---_----Foundation-----_---.-....._----.__.Prop• tine----...-•--------------•--- REPAIR/ADDITION (Prev. Sanitation Permit#-------------------•--------------- ----------._._.Date---------------------------------------_------J Septic Tank (Specify Requirements) -� Disposal Field (Specify Requirements)-...... ........... -------------------------------------- -------- --------------------------_....--- -. ------_ -----------------•---•-------------------------- -------------------------------------- ------------- - - ------------ ...... ..................... ---------------------- (Drow 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 become subject to Workman's Compensation laws of California." Signed ��1-�� -•. --.7 - +G /..i ----------------Owner By---------_------------- ---------.Title -- - -------------------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE OtJLY APPLICATION ACCEPTEDBY.. :............ DIVISION OF LAND NUMBER-------------- -------- --.DATE.------ ............ --------- - ADDITIONAL COMMENTS-- ------- -- ---_--.- -------------•-••--------------------------- -----------------------------•---•------------- ----------I•-----------------------------1111 - ----------------------------------- --- -------•- Final Inspecfton by. -- ---------1.111-1111-- - . ------------------1111-- ---------....-----------------------11111111-1111-- -- --Date------------------------- ----------------------- EH ---- ---- ------ -----EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FGS 21677 RFV. 7/76 3M