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"..FOR OFFICE`Usk FOR OFFICE USE: • ?,.1;,- APPLICATION FOR SANITATION PERMIT 77� 55�� P. it - --- ------------- vaN 0y �-► (Complete in Triplicate) Y Date'Issued_&-._x:5:_7 ----------------------------_----_------_---------_______ 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 Co ty Ordinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOCAT N - 1°' -- = -----=------=---- ----- ------- ------ t------ --- °---.CENSUS TRACT----- ----- --------I.--.--.- - --- I ; Owner's Name.------ -- Gam.: it` -------- - - ----- ---- ---------- • -- - t Phone 9g� Address r�-moo. -- - ---- - --- --- ----------`City ZiP Contractor's Name= +%�� License # > - Phone t .. ,. . ---- --- ; -- Installation will serve: Residence [ partment House.❑. Commercial ❑ ;Trailer Court ❑ ' ,... Motel Other - } Number of living units:__:_._.______Number.of.,bedrooms_.__9-_-_Garl/baage rirr/7)�dafrlr------- Lot Size..-.-_L-�.-,�E_.��-�-__.___..______________ Water Supply: Public System and name=.- -_:-.------------- ----`---'------ ----------_-=.-.: =-Private s Character of soil to a depth of 3 feet; Sand Silt❑ Clay❑ `:. Peat [} Sandy Loam ❑ Clay Loam ❑ Q i ' Hardpan � Adobe-Fill Material_:__.__._..J#yes, type-__.__________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.'must be placed on re'erse side.) NEW INSTALLATION: (Nonseptic tank''or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK-'H1-' I Size'-._"""'_ F'------------------------ Liquid Depth._.---.- ----_________s__ ; s i ___ -..Mater'ial '= = No. Coin --- -- Ca acit E :T e - - `- partments--". ----------- 'Foundation t t P Y- T . YP: = to nearest: .Well:: ---- `---=--------------------=Foundation.--------'r:"-----_-----Prop. Line--------'----------------- Distance . LEACHING LINE. [ ] No. of Lines.;=- .-- --.--- '--- Length of each line---=Y=- .- :----.----Total Length ;- 1------------------------------------- D' =-------------------------------D' Box--- -- --'.._Type Filter Material'----- -----Depth Filter-Material: ----------------- -------------------- i Distance;to nearest: Well-;------ Foundation-----------^------------------Property Line-------------- ------------------- 6.. SEEPAGE PIT [ ] Depth._!------.- Diameter.------- - - -- •� �; t t S«.....:._..�... ------ ---- Rock Filled Yes ❑ No R Water Table Depth t De th---= -------------------=------=- -- Rock Si --------------------------------------------- 7a f4. Well - - _ __Foundatio'n;_ � Atop. LineDistancE'to near'e'st.: Y - ` REPAIR/ADDITION (Prev: Sanitation-Permit#-.------------- --- ----- --- s _Dat...... _ `-- F Septic Tank {Specify Requirements) _ ff q -- x �•,s� pp 5 Disposal Field (Specify Requirements)------- . . ---- ------- - - ----------- r ------------ ! Ad ,. - ------------- ------------------ ---------------- --------- (Draw' isting and re irecl addition on reverse hereby.certify thatI 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 sha I not employ any person in such manner as jest toWo to becom . an's . o p,ensation laws.of California.' Si Wed -=-------Owner ' . - ----- -- ---- --- -------- ---.- -. Title- ------ ----- ----- ------------------------------ r (If other than ner) f FOR DEPARTMENT USE ONLY t r APPLICATION ACCEPTED ------ -------- ---- -----=4----=-- -----------DATE. - -------------------- DIVISION ---------- ----DIVISION OF LAND NUMBER:..: -' --- - ------------- ------------------ T DATE. - ------- --I--- I - ADDITIONAL COMMENTS------------------------ -------------------------------- ------=-------------------------- == , ------------------ I -------------------------- - ` s ------------- -------- ------------ - 1 _ _ ----- -- -aFinal-Inspection EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M