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FOR;OFFICE USE: • APPLICATION FOR SANITATION PERMIT FOR OFFICE USE- APPLICATION No.._77-_J Sl : (Complete in Triplicate) �l - : _ ,Date Issued --g-_.=�6-__7.7 - This Permit Expires 1 Year From-Date Issued Application lication isr hereby made to the San Jaa uin Local Health District fora erm�itao construct and install the work herein described. PP y q This application is made in compliance with County Ordinance No. 549 and exi st_ingRules and Regulations : JOB ADDRESS/LOCATION / ------- - �- -------------------- -----------------x.0EN TRATRACT ------- Owner's Nore � - -� Phone Addr ss. -- -- � - - --------------- --Zip-- -rF-a -33- ------- Contra or s .ar4 ___-- - -- --- g-- - -- -----License #. _ . - . - ! �k ` -,� -----� :�� g�-�-1 ---Phone---��1 Installation will:serve: -�iResidence W Apartment House.❑ Commercial E] -Trailer Court E]Motel ❑ - - :---------- Other p. Number of living units------- :_Nu.mb�er of bedrooms.._- __.Garbage Grinder..,_--_-[_Lot Size---� -- Water Supply: Public System an'a name] :-------------------------- -------- - - --- Private f❑ Character of soil to a depth of Veet: Sand ❑ Silt E] 'Clay ❑ Peat ❑ Sandy Loam A Clay Loam 0 Hardpan ❑ tAdobe❑ Fill Material__---------If yes, type---------------------- ! (Plot plan, showing size of lot, Iocatibnlof system in relation to wells, buildings,'etc. must be placed on reverse side.) NEW INSTALLATION: 4i ` ,(No'septicAtank or seepage pit permitt=ed if public sewer is avaiiable+within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK E 'l Size--"_L Q y . 'y_ � Type rJ� ---- -rater al�_ �� __.-No. Com artamentDe__ Capacit�� Il, P q Distance'toFoundation_=:-__3._P______-------Prop. Line.__.,------------------ .__-.-__'Length - LEACHING LINE D' Box:-- -- --._ s .... . ' .-- ------. . hJi.na "� * f f. :i � i � ��-------•----___Total..Length.-.- -�--��------------- ------'-- .. .. Lengt�f�ac---:-De � # , No. of Lines-:- iType Filter Material---- -- p Filter Material----- - ------------------------------,----------_ - 9 t Distant to nearest: Well_;_J_�.�_-_ -----Foundation-----------------------------Property Line--:---------------------------- , T [ l Dept J� ------- i eter _Number------------- _--_------- Rock Fillet! YesFjk No ❑ Water Table Depth.-, / __ !% Rock Size__-_- �'� t ---- _ bistance.to nearest: Weil._ _` "- '� ! == Foundation 1 d-- -.Prop Lin _ w, REPAIR/ADDITION (Prev. Sonitation;Permit#_--...rte,... -___-_ :__.Date.______-:'___-______:_ ------ } Septic.Tank (Specify Requirements))-----t_ _:' _ . Disposal Field.(Specify.Requirements)__ ._.:_;-__.--- -----------I------------------------------------ = ----------- :------ ------------,------ ------------------------------------------- ;I ---------------------- . --- -- - - ------- ------------------------I''-- _ ------------ } - ---------------------------------------------------- - -- ------------------------- ! (Draw ezisting�arid required addition on reverse side)" J I hereby certify that I have prepared this"application rand 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: l i "I cern that in the � ` certify performance ofthe:work'for which this permit is issued, I shall not employ any person in such mann er� gs to become subject to Workman`s Connpe sation laws'tof California.". [ Signed I 1 r a i B ... �.{. s ------ Title = I_fother an ow er i u: d ... I • .. j. llll � ':FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__:-_ ------------ __- ______. �! = DA DIVISION OF LAND NUMBER.._ TE 4111------ ------- ---:---- ADDITIONAL COMMENTS--- _ -__-'_.. . .� ---____-- A-- -- ---------- --------------------------- -------t--. --- = ____________ e______.__ - iU i� ____________________ :- - -------.--------------------------------------.------------------------------------_----------------.-------------_._._-----.Final Inspection-by.-.-- F �. . . �., ate Y " - -------------------------------------------------- EH 13 24 :i USAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7176 3m