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n* - 1 FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- -------------- -- ---- ---- ------------ Permit No.---7.7--.6 3 L 1p, �- r (Complete,an Triplicate) -------- Date Issued---- ......................................................... This Permit Expires 1 Year From Date Issueci w jj 2 t s o ,E. A OLO�✓�y L.,j , L �3—2-�O 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. - - -------------------- - --C ENS US TRACT .------------- -�----_-_ -_-_-_-_- _ Owner's Name___ - ----- -C- - C------ --------------------------Ciy--- ,- ------Phone Address.1_; ///------ --- -- -- �- --./r -C,------- ----------- ---- .. -------------------Zip- ----- -------- -------- ' q C� 11 Contractor's Name-- Ld' .` ttL - ------------------- ----------- --------License # ��f 1 -.Phone_.7_ s�o�-/�--- Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------- - - ---------------------------------- Number ---------- ----- ----- Number of living units:-------/__Number of bedrooms--4:3---Garbage Grinder------------Lot Size__ �--�` - i Water Supply: Public System and name--------------------- .- - --- ---- ------------------ _________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 lat;location of system in relation to wells, buildings etc, must be placed on reverse side.) I NEW INSTALLATION: (No_septic tank ori seepage ,pit permitted if public sewer isvailable within 200 feet,) f PACKAGET.REATMENT SEPTICTANKe_ ` � h - S. _ Liquidt /CapaciDept .- Materi � -- - ----------- I --' . Distance to nearest Well--- -----------------------------Fovri-dation.-/10................Prop. Line- -- Length of each line.y - f , s LEACHING LINE � NDo. of Lin�..= T e F Iter Material_5f�4C e th FilterMaterial -Total th^__--_�->�d=----/-_.---___---, --� F Y,P / P Distance to nearest: Well.. 61 Foundation___. ( .�' _Property Line__ f �--- A , t r� TZ f` J SEEPAGE PIT [Y Depth..49-�___-Diameter.____.✓__ �f-Number--- ----�--- ------ Rock Filled YesX No [ ' Water Table Depth.---------f .lQ ---- --------------------------Rock Size--- --------------------------------- Distance to nearest: Well.........1,5_7)---------------------Foundation-----6__,5_----------Prop. Line__-- l t--- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date...._....-......._..._-----------------....) r SepticTank (Specify Requirements( ------ --------------------------------------------------------------------------------------------------- -- ----------------------------------------- Disposal ---------------------------------------Disposal Field (Specify Requirements)--------------------- -- ---- ------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manne to become Iect to Workman's Compensation af, C ifo ia." Signed / / ��``��- g �.. - owner $Y Title. -- ------------ -- -------------- ---- ---- -- i.. (If other than owner) FOg WARENT USE ONLY APPLICATION ACCEPTED BY------------- � -- ----- ------- ----- -DATE - -- -- --------- --- DIVISION OF LAND NUMBER ---------------------------- - - -------------------------------------------------- ----_DATE.-------- - -- ------- -- - - - ADDITIONAL COMMENTS--- ---- ---- --- -------------------------------------------------------- --------------------------------------- ------------- ------------------------------------------------------------- ---------------- ------------- --------------------------- -------------------•--- ------ ---------------------------------------------------------- - -- - ------------------------ Final Inspection bY=----------------- ',.� Date__. 1 L- EN ]3 24F&S 21fiREV. 7/76 3M ZNOAQUIN LOCAL HEALTH DISTRICT