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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -7 7, ------------------------01111 ------------------ (Complete in Triplicate) Permit No. -- ------------- " ------------------ ----------------------- -------- Date Issued__ This Permit Expires 1 Year From Date Issued /IJCW J'jr �bei 14 1 u utS-e-1 Application is hereby made to the San Joaquin Local Health Dis'frict 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: y� JOB ADDRESS/LOCATION- ` .•------------------'..---- ---.CENSUS TRACT_.-- --------------------- Owner's Name.-----14 Phone--------------------------------------- 4W . A Address------.tel--�C`1.3_. J O-s/�--- -=-----=----------------------- - City Zip Contractor's Name- se #. -ga .-__Phone_ + 1___- Installation will serve: Residence -4-Apartment House-E Commercial ❑ Trailer Court ❑ " �� '... Motel ❑--, Other-- -- -- ----------------- ------------------ e --------------- s Number of living units:_____ -Number of bedrooms:._--Garbage GrindexC�._Lot Size_._. O- ': _G._+4:,___v,..:......... ... Water Supply: Public System and name------------:- -------------------------------- _ ----------------------------------- =__ _:; Private Character of soil,to a_depth of 3.feet: Sand]'Silt❑ ClayE-]., Peat❑ Sandy Loam ❑ IClay Loam ❑ Hardpan❑ : A;dob�❑ 0 Fill Materidl_.._��_If ye's, type------------------ ------------- (Plot plan, showing size of lot, location of'system i relation to wells, buildings,`etc..-must be'placed on reverse side.) NEW INSTALLATION: (No'septic;tank or seepag#,pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ .]..tSEPTICJANK ['.] # :± Size--------------------------------- --------------- --------- Depth._ - ----- - ) Capacity-1260'1260.._._ ---_Mate-rial_dVAA&&-V1"_No. Compartments -2. ----- -- Well �1 ----------- -Distae: ant --------------Prop. LineC' 1�---------�- : 14 do "CEAtt—H( G LINE [�] No, of Lines_!_ � -� Length of each line._.;._ _ g ' ©-,--- - ---.Total Len th.__.. -43P 1 -------------------------- . - . D Box._ z._ ____Type Filter.,Material---------------------Depth FilteMaterial------------------ -_--___-- ---y___.___-_.----------: -- . :.. Di anceto nearest: Well __ _ _____________ __ foundation.___ _' =__..Property Line----------------------- _._C `7} SEEPAGE PIT [ ] Depth._. Diameter :_--- ------Number-----------------------------------_ F Rock Filled Yes E] No ❑ Water Table=De th----------=------=-------- ----=------=------ -----------Rock Size_ ------ i 'Distance to nearest: Well........,_____'------ --------------------Foundation-------__.-.---4------*_.Prop. Line-------------------------- REPAIR AD t i. ; .� DITION (Prev-Sanitation Permit#_._. '- = _ Date =`--=----- } ' 'J / c�a <y, k Septic Tank (Specify'Requirements) = a = = -:_' ==- -- ----_�---- k I . u . }'L*)- --------------------------------- ----'---- ---4---------------------------------------- t Disposal Field,(Specify Requirements)-,--` �� E .- ----- ----------------------------- - --- --- �' `. ---- ------ -- ------ -- ------------------- ----------- ---:-- -- ------------------------------:------------- ------------ (Drawexisting and required addition on reverse side) I hereby certify that I have prepared'.this application and that the work will be done in accordance with San Joaquin County Ordinances, State Law_s;, andtRules1,hd Regtila.tions--of:the-San Joaquin Local Health District, Home owner or licensed agents signature certif es tW ffollowin1f: ' "I certify that the perfor nce"of the work for which this permit is issued, I shall not employ any person in such rnanner,as to BY-b-. come�subject--<-t� o or--k-maa.n4 Compensation laws of Califor n ' ia Si pe _ -------------- Ow"n.e.r------ ----'--- ------<-------- -----.Title-- -------------------- - ---------- ---------------------------- AM- (If -------------------------"' (If Ser tAon owner) . ' a FORMEj4TMENT2SE ONLY APPLICATION -----------------------BY------------- DATE. ----------- -- DIVISION_ OF L}A,,.N, D NUMBER----------- ---------------- ------ �------ -.-.-:----- ------------ ----------.DATE.._ --'---- ------- ------------------------ ADDITIONAL LsVMMENTS------------ QU = S 'tf,.�A------------------------------------- r �--------------- -'------ --------------------------- ---------------------------------------•----------------- _ ---- -- .---------------- ----------------- _ _i #- ------- -------------------------------------- -------- ---------- -- ----- - ----------------------- ----- Final Ins ection b —, . _ ___ __ __ . ^�� "` - Date ---- --- ---- --- ---- p Y —. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV. 7/76 3M