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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: -------------- ---------------------- (Complete in Triplicate) [Date rmit No. -- 13 Issued-../Q_"-7_-77 " This Permit Expires'1 Year From Date Issued _ d - Application is hereby made to the San Joaquin Local Health District for a permit to const uct and i stall the work herein described. i 1 This application is made in compliance with Count O i nce No. 549 and existing Ru es a d Re ulations: t *721 JOB ADDRESS/LO TION -� � ,z r_u✓ - t� {~ , : ._.CENSWS..TRACT-------------------- Owner's Name Address_ :. hone � .� = t --- - - _y Criy Contractor's Name__ T � e.4--. - #-2-Sy- J, a. zip (¢ = , License #. _�' �- ` --Phone__—_�- � P Installation will.serve: Residence Apartment House. f ❑ Commercial ❑ Trailer Court ❑ +' Motel Other ------------- ---------- ------ --- w Number of living units:-----/ Number of.bedrooms___- _ ----Garbage.Grinder---,--------Lot Water Supply: Public System and"name-----. ' ' -------------- - . ------------------------------ vat _ ri e , Character of soil to a depth of 3 feet: Sand ❑ :Silt❑ Clay ❑ . Peat Sandy Loam Clay Loam ❑ Hardpan❑ Adobe-❑ i Fill Material._._ :- T _. If yes, type-------- . t -------------- ----- -- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) j NEW INSTALLATION: .(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] 'SEPTIC TANK '[T]A"t`-----'' Size '__.___`_.::_ ' { i I t `- Liou� Depth._ : Mate ial Foundation d No. Compartments_ # -- -- Distance to nearest: Well g:.. _. oun ation-_ - ---�r- Pta 7n :: %. LEACHING LINE [ j No, of Li.nes__-_--___._ _ ____...'Len. th of each line___ i g -.Total Length 'D' Box F i._T a Filter Material� --- ---------- i�:- � -------------- , -- ---- - ,,. - -._--------------- -- 4 to nearest: WeIL'__1_- _ Depth Filter Material__ _ ff D i stance Pr' l Foundation .:--' -r. .. ;__..Property Line- - SEEPAGE PIT - .6 }.-. .. ,. € - _ _- -- -- --- - I ] Depth -- ............... _; .Diamter ----'- Number--- ------ --- -- ! ''❑ Rock Filled Yes❑ No Water Table Depth--------- -- ° Rock Size-------------- Dist ahce -------- --Distance to nearest: ='- -4- Foundation Prop, Line REPAIR/ADDITION (Prev. Sanitation-Permit A#C- - :# Date— `= . ------------------------- Septic Tank {SPecifY Requirements)__---, ____________ __________________ --- a � = - rN� y DisposalFieldl(Specify R'equi'rements)-- ___________'_ -- --------------- - 17-- ------------ --------------------------- : .' - ------------'-------------- (Draw existing and required pddition-on reverse side) I hereby-certify-that I have prepare Phis application and that the wprk_wiII; be=-done in accordance with San 'Joaquin qu n County d Ordinances; State Laws, and Rulesaand Regulations of7th n Joaquin Local Health District, Home owner licensed agents sig ature certifies the following: _ �-. - s - # If t l certify that,-In the performance of the_work for which this permit is issu d I shall not employ any person in sucFi manner as to become subject. to Workmn s aCompensation'°.laws of California;", Signed---------- ----------------------------------------_ g v 4 [ --- ---- -- . = = ' (If other than_owner)•�; •f . < ' 'FOR-DEPARTMENT USE ONLI- ON APPLICAY]ON ACCEPTED BY__ DIVISION OF LAND NUMBER ! - *.. - .___ DATE ADDITIONAL COMM•ENTS.---1_It------"-__,.---'t �' -- DATE-'--- --- ----- *. --------------'------------------ -----------------------------------------------'J_. f --..--------_------ -------- d l ----- ---- ------ r - --------------- --- --- Final Inspection by:_ -_ = s------ -' { ;; ' --� � . _... ..;_---'__`Date-EH 13 24 - ------- - ------- ---------- c �< N SAOAQUI LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M ;