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FOR OFFICE USE: FOR OFFICE USE: " _ APPLICATION FOR SANITATION.PERMIT , --------- ----------------------------------------- (Complete-._Triplicate) Permi# No. -_7-w _____________________________________________________ _ 1 �. Date Issued�4z f9/_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 C- my Ordinano. 549 and existing Rules and Regulations: `7 - f�" 1 E JOB ADDRESS/LOC TION---------------------- -- ---_----------------------- ------------ �. I._ CENSUS TRACT -------__--.- 's Name--/-- _ �' - hone -- ------------------ Owneri - - - •. �.. ems. �_ .. Address 3 � - - .. `City Pc� �� T P s _ x. ... J Z i Contractor's Name- - _. __` ----- --------------------- c'_License#.-�l' - l _ _Phone --- ., �. _ _.. ..,}_ � w . f Installation will serve: Residence j` Apartment House E] Cornmercial ❑ Traijer Court ❑ s Number of living.unrts:_____. __'__ Number of bedro s_ rba e_Grin Lot_Size.:_ .._ Y > Motel Oth_'er_. r -x/4--- s --------------- ~� dam:---�=_._-=:_ k ��---- t t ;' t i' P Water Supply: Public System and.name--- ::---- � - _ .Priya#e ❑ Character of soil to a depth of 3 feet `� Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam El i Hardpan ❑ Adobe Fill,Material-..__; _If yes, type--------------------------------- 7 .__.__ _ - _ : ______ I (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 avai,alile within 200 feet,) I , PACKAGE TREATMENT t SEPTIC TANK "'� ""� - ------_ '_-___Liquid Depth.._.___; [ ) [Y) � Size-- `----`-------:' - ----- --- t # � . - r Capacity_----- --------------:Typ6___::;!r� ,- -Material--------------------------No; Compartments--------------------------------'.---- 3. ._. . Distance�to nearest: Well-.-.- ._:---------------------------------Foundation -_-: . t_-Prop. Line_____________ v LEACHING LINE? [']; '7No. of Lines __.-:_ ,,Length of each jine--. _ ,Total-Length -- '- D',Box ._---------Type Filter Material_' :_____Depth Filter Material-_____________ _'_{- _ 4 Distance•to,nearest: Well_:_____________------------Foundation------------------------ ___.Proper Line----------------------------- SEEPAGE PIT [ ) Depthi- : __:Diameter.:_. _ ___.Number__'____.____.__ Rock Filled Yes ❑ No iWa4r'Ta b I e!De pth---------- -------------------- -----------------Rock Size=•------------= _ Distance to nearest: Well----------------�--f---------_¢_--_--.Foundation----------------:-_..----.Prop. Line--------i------------------� r REPAIR/.ADDITION (Prev.'Sanitation Perm ------------ _ --. `.^____Date ------------------------- Septic ___-__ _____-----_Septic Tank (Specify Requirements)----- " ={= = - ----------------- w f r »------ a Dis osal Field (Specify Requirements)-�.0 0`_'�.-~1/_- -/Q -- -- -------- ---- -___._____._____ _ _ __. ____.______.____.___ __._._.. - # t (Draw existing and required addition on reverse- I hereby certify that I have prepared this application-and-that.the...work-will-be,_.done_invaccordance with San Joaquin Count Ordinances, State Laws, and Rules and Regulations of; the San Joaquin Local Health District. Home owner or licensed agents i signature certifies the following: k l "I certify that in the performarice'of'the'work-for which this peijii it is issued,_1-shal'n lot employ any person in such manner.as --" to become ct to Wo, man's ompensation laws of California.': Srg ned . -- . N. Own' er------ ------------ By,; i ' �- C--------- ------ -------- -- - Title------- --- -----` --------------------------------------------------- (if ----- ----(If I r 1 other than wner] ? 6 I ` 4'°'----FOR-D E PARTM ENT-USE"O N LY" r APPLICATION ACCEPTED BY --- -- ---DATE -` DIVISION OF LAND NUMBER ---------- ---- ----- ------------------DATE- ----------------- ----- ADDITIONAL COMMENTS ---------------------------------------------- ----------- ----------- --L--------- # -- ,---------------------------------— --_ - -------------------------- ----------------------------- ------ --------------------------------------- ------------------------------------------------ --------------------------------------------------- - --- - ----- -- - --- - - - D -. -Final Inspection-by: --- ----`-- -----= --- ate ------------------------------------ ------- EH 13 24 F- ,SAN JOAQU LOCAL HEALTH DISTRICT 8e»'�� ---- - #f REV / 3M