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r - FOR OFFICE USE: 4/ FOR OFFICE USE: APPLICAii. -SANITATION PERMIT -- ------ -------------- _ (Complete in Triplicate) Permit No.____-------------- ------ ----- _ - -------.-. --- �-------- Date Issued_�_.:1:�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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ! �rrt"Y° "---'"- CENSUS TRACT-_- _.--_..____ r Owner's Name--- ------ - ---.------------ -- ------- --------- - Phone-------------------------------- ---------- Address - City- -- - - -------------- Zip----------------- - Contractor's Name--------------------- - ------------ ------------------- -- y ` _ - w License #.,2.-1-53.�..._ -Phone__;;' -r2G�� Installation will serve: Residence ❑ Apartment House❑ Commercials Trailer Court ❑ Motel ❑ Other----------- --------------------- ---- --- _ Number of living units: of bedrooms____ Garba--a Grinder------------Lot Size-- -------------------------------- Water -.---.-._.--.---.-_-.--.-.._Water Supply: Public System and name--- ----------------------------------------------------- ---------------- ---------t----------------------------------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-t6 wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted ifRublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK �Si ---_ _�---------------_-Liquid Depth`_/y____..___ Capacity_ryJ- V -----Type ' ------ ----Material.- -----------No. Compartments------7---------------- ------ r Distance to nearest: Well-_A-00 ---------- -------_----/-Foundation---Ze------__Prop. LEACHING LINE Q<' No. of Lines.-_-�__.__--._Length o�3 ffeach line`--�d---------------_Total Len _ _ _ Length _36� .- -_-_--------_.--�{t 'D' Box.-.l------Type Filter Material. 4.4 _-Depth Filter Material---Z2---_--.--- -.--- --- ---_----_--_--.-.-----. .. r r Distance to nearest: Well--/QD--�__--_----Foundation--/Qct--.-_.-----.--.Property Line_- _ --------- SEEPAGE PIT ]" Depth_v ___Diameter- Number------53-_----_-.---- Rock Filled Ye No rJJ3r ry ❑' Water Table Depth-----o _f-- -Rock Size-�G __-_-------_------- ------- Distancetonearest: Well_-f.`� __............._-_-_-_Foundation_ -__..-.-.Prop. Line__-.- - -.--.-.-- ..--._ REPAIR/ADDITION (Prev. Sanitation Permit#__-____-__..__--_---_--....____Date.--__.--_---------------------_-----..----) Septic Tank (Specify Requirements)---------- ------- -------------------------------------------- --- - --- - L ----------- ---------------------------------------------- --. Disposal Field (Specify Requirements)----- --- - --- - - - - - — — - - -- - — -- - - -------- ------ - -- --- -- - ----- ------------------------- ---- --------- ------------------- --------------------------------------- -------------------------------------- --------- -- - ----------------------------------------------------------------------------------I----`---------- ------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) L 1 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 Lsignature certifies the following: "I certify that in the performance of the work for 'which this permit is issued, 1 shall not employ any person in such manner as to becom ub' t to rk�m�'s Compensation laws of California." ` Signed_ _4_-✓orf` "�-f.�_ Owner By--------. ...... --------------- ... ----- ---.Title- ---------------- - (If oth(r than owner) L - --- / FOR DEPARTMENT USE ONLY �7� APPLICATION ACCEPTED DATE.-..- _ __.. __ _ --/------------- ---------------------------------------- DIVISION OF LAND NUMBER - ---- ----------- - - - ----- -DATE.- -- --...-------------- - - -- LADDITIONAL COMMENTS -- --- ---------------------------------- ------------------- --------------------- -- ------ ------------------------------- - ---------------- -- - — ------------------- -- -- --------`----------- ----------------------------- ---- ------------------------------------- ----------- ------ - -------------- ------- - LFinal Inspection by:_-_----.-----_---_-_ - - ____ --- ----------' - ---- - --- - - -- --- --------Date.-- ---�----- ��-7-/�j-- - - - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT . Fas sibs ek v. '/76 3M