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a L o° � �� G�-� �( 2 t ! 4"FOR OFFICE USE: FOR OFFICE USE: -------------------------------- -------- APPLICATION FOR SANITATION PERMIT------ -- - Permit No.---77-7!q (Compkte in Triplicate) ---- ---- ----------------------------------------------------- --- Date Issued-O!73 —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 �Countyinance No. 549 and existing Rules and Regulations: j 1-1JOB ADDRESS/Lr.Ae_ TION_2.-_�-L------- 4/ --------------------- ----------------------CENSUS TRACT - Owner's Nam e-- - ---- - -- - ------------------Phone-------------------------------------- Address------------------------------------3esidence --- --------------- -------------------------------------------City--------------------- --------------- -------Zip------------------------------ fraContractor's Name-- ----------- ---------------------------License # Y PhonesS-= �. Installation will serve: Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------- ---------------------------------- Number of living units:----------------Number of bedrooms_. -------Garbage Grinder------------Lot Size--------------------------------------------------------- _ WaterSupply: 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 lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth ____________-_--_--- /CapacityAV4 ype.__o +la.Y_Material_________________________No. Compartments_.__.. ''�______________ _ Distance to nearest: Well_________________________________________Foundation----/40__--------------Prop. Line__ ______________ . LEACHING LINE [ ] No. of Lines-----------------------------Length of each line-------------------------------Total Length __________________________________ p Box_ 11`e Filter Material_A0_541-_ _Depth Filter Material---_`L__o-------------------------------------------------- [3istance t0 neareO: Well-----------------------------Foundation------ ___-_.___-------------Property Line------------------------------------ SEEPAGE PIT [ ] o epth------------_ _Dia r� ___-______ _____Number-------------------------------- Rock Filled Yes E] No Water Table lTepth------------- ------------------------------------------Rock Size------------ Distance to nearest: Well------------------------------------------Foundation--------------------------Prop. Line_______________________ REPAIR/ADDITION (Prev. Sanitation Permit#______-__. Date------------ ----------- -----------_____---------------- -----) Septic Tank (Specify Requirements)------------------- �A---------------------------- ------- - Disposal Field(Specify Requirements)_. �- � . 4 e --- ----- --------------------- — ------------------------------- ------- --- t ti / _____________________________________________________________________________________.F________-_-_--_____s____-____________________-____________-__ ___________________________________________________ �' (D4aw4alst QSVan,d required gddition on reverse side) I hereby certify that 1 have prepared this3pa ptR1pri-cmd 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 ag nt signature certifies the following: A� "I certify that in the performance of the work far-which this permit is issued, I shall not employ any person in such manner a to become object to W rkmanIs Compensarlisn-Jews l0f California." Signed----ZA—2F --------------y r`�. - Z3viinhr--_. BY----------------------------------------------------------- ------------------ `--------�.--..Title----------------------------------------------------------- ------------ (If other than owner) r FOR DEPAR NT USE-ONLY 7 APPLICATION ACCEPTED BY----- --- ----------------------DATE.-------- -c;:76_ f ----- DIVISIONOF LAND NUMBER ---- -------------------------------------------------- ------------DATE--- ----------------- ----------- ------ ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------------•-------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ---------- - ----- ------------------------------------ ---------- - ------- ------- --- --------- ------F h --- - _� - - ---- - -- -- -------------- -- - --- ------ - --- -- --- ti a^i s _ -7 Final Inspection bf' � --- ----- - -- Date .. f -- 1 EH 13 24 �' SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M