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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 77 Permit Na. ----- -- - --------- ---------- ----------------- - -- i (Complete in Triplicate} _�/73- ----------------------------------------------- --- 1 Date Issued --�--- --..---- This Permit Expires 1 Year From Date issued f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application �mae m compliance� pliance with�ounty Ordinance No. 549 and existing Rules and Regulations: is. � CENSUS TRACT _�_._- - --- . JOB ADDRESS/LOCATION-._ '27`f ` ' Owner's Name ---- -- ------Phone ------------ ---------------------- Address ------- ---2-7fY7 ----c-------- ---------------------- - city --------------------------------- ...... r Contractor's Name ------ -------- ----- - -- -------------------- ---.License # --------- ------------- Phone ---------------•----------_- - Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other _" g-`-` =-f------------ -------•-- Number of living units:_-.___ I ' ` g .�-___ Number of bedrooms _. t____GarbagFl e Grinder . Lot Size . jE �"~ Water Supply: Public System and name ----------------------- '- --- ---------7------------- -,;-----------------1.0------------Private Character of soil to a depth of 3�feei`, Sand'❑ ilt❑ Clay ❑ Peat Sandys Lodine f `'Clay-Loam Rr Hardpan El Fill Material _ If yes, type -SI-------------------------- (Plot plan, showing size of lot, location*of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or p seepage pit permitted if public sewer is ovaildble within 200 feet,} PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size---------------------------------------- ----- Liquid Depth -------------------------- Capacity ----------------- Type = =- Material±'----------------- o. Compartments I Distance to nearest: Well ------___________________ ----Foundation ------ --------------- Prop. Line -----------------------0 LEACHING LINE S No. ofLines ---------------------- Length of each line___ ___________ _______ _ Total Length --------------..___•.--.--__ D' Box -------- --- Type Filter aterial ________ ___- '___Depth,-Fitter M terial _________________________---._____-.-•__._rn -- f �t 'd - aft Foundation , ` = -------- ----- Property Line. -------=•- ------------- Distance to nearest: Well ____ __- f SEEPAGE PIT [�] Depth ____________ ______ Diamet r ________________ ;Number Rock Filled Yes ❑ No l Water Table Depth --.-------- ' ---- ----Rock Size -------- --- - 0 -- ------------ i ce to nearest: Well ---------------------------- -Fo`ndat ony Prop. Line % REPAIR/ADDITION(Prev. Sanitation Permit_# --------- -- - --`--------------------------- Date ------------------ 1 , N _____---------_} -..•--- --- ---------------••-- (Septic Tank (Specify , ----------------------------------------------------------- •-------- Disposal Field I$PcY Requremenfs_'l _�--------�--C��---- -------�_mc------ `f r----- --------------------- ----------------------- 4 G!. �! �{ - --- =`}----------------------------------------------- (prow existing and required addition on reverse sidej� # thereby 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 an& Regulations of the San Joaquin.Local Health District. Home owner or licen- sed agents ignature certifies the following: y i "I certify t at in the ormance of the work far which this permit is issued, 1 shall not e m ploy any person in such manner as to be a subject Workman's Compensation laws of California." F . Signed --- ------ -------- -----------------------------r-----------------------------. Owner ------------------------ --------------- --- ' ---------=----------�-�_�� --------------- Title - - --.. --------- (If other than ow I er) ' FOR DEPARTMENT USE ONLY GACCEPTED BY I- --- ` � DATE . -- �1� -------- APPLICATION �P_ -, DATE - - — ADDITIONALCOMMENTS ------ ------------------------- ' -~ '-� -t- `-= f' '= ._ ._.---------- ------------------------------------•----------- ------ ----------- ----------------- -------- --------------------------- --- -•----- --------------- ---- `---------- ------------------------------------------------------------ _�.. _ ---------------- Fina Inspection b Date __---- -r - .- -- - - --------------------------------------- ------------------------------------------------------------- ---- ----------------------- --------------- �, i SAN JOAQUIN LOCAL' HEALTH DISTRICT E. H. 9 ? Rev. 5M - i � _��_