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FOR QFFICE USE: FOR OFFICE USE: - Ir APPLICATION FOR SANITATION PERMIT y o---- --- - (Complete in Triplicate) Permit No--- ----------I----------- --------------------- ----------------------- -------- Date - - --------------------------- Date Issued---e d' 7--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. 544:and existing-Rules and Regulations: JOB ADDRESS/LOCATIO -rAN ----- JnH Q+< 7CL v (� L-oT � _ __ _ �ZCENSUS TRACT------------------<-'�' --- - - Owner's NameM-------------©--1/I- ----------------------------------------------------------------------------------Phone------------------------------------- Address-------34�-p00 J-64-S;Fper...lisel----------------------------------------City-745e ---------------------------zi Contractor's Name-----_ _ .T' a.n��------ _____ _ _____ _____________License #-lPE_S3'6_.__ Phone-------5 Installation will serve: f Residence X Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------- --------------- Number of living units:-----j---------Number of bedrooms__ __Garbage Grinder---.--------Lot Size-------------------------- ___- WaterSupply: Public System and name---------------------------------------------------------------------------------------------------------------------------------Private ❑C� 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--------------------------- Capacity_P�Od--------Type_A'C_-CAs?_Material----CSN-- ------No. Compartments-------A-----------------------10 Distance to nearest: Well--- --------______________---.--__-___.-Foundation_.__tc'__`_------------Prop. Line____ J____._.._-.__.� LEACHING LINE [ ] No. of Lines.9_J_'X_�-4_`_______Length of each line-------------------------------Total Length._. ._____________--- j 4 7�-p; ,0e�e/ 'D' Box------- ---TYpe Filter`MaterialAr'14?------Depth Filter Material----�v-1------------------------------- --------------- Distance to nearest:Well-----------------_-------___Foundation------ -------------Property Line_.----� �_ SEEPAGE PIT [ j - Depth.---------------Diameter_-----------------Number-----------------_----------.--- Rock Filled Yes ❑ No Water Table Depth---------------------------------------------------- ---Rock Size ----------------------------------- Distance to neare3t:.Well-------------------------------------------Foundation_-______________..____-Prop. Line_.________--__________----- REPAIR/ADDITION (Prev. Sanitation Permit#-_ .___..__._--______-----------------Date___,__._-_________________._____._-._-___) -t- Septic Tank (Specify Requirements)---------- ----------------------------------------------------- --;-- . S DisposalField(Specify Requirements)-------------------- --------------------------------------- ------------ --- ----------------- --------------------------------. --- - ---------- --- - r - <--- ---- ---- ----- - ---- -- ---- --- ----- ------- -------- --------- -----------J i j ----- ------------------------ ---------------------------------------------------- ---- (Draw existing 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 Laws, and Aules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents 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 manner as to become subject to Workman's Compensation laws of California." Signed------ ',_A_A/7_APA.. -----� .SQt.Y--------------------------------Owner BY----------i -- - - --- -------------------------- ------------------------Title----- ----------- ---------------------- ------------------------- than owner) FOR DEPA TM T USE ONLY APPLICATION ACCEPTED BY ---------- - ---------------------------------DATE - DIVISION OF LAND NUMBER--- ------------------------------------------ - ------------------------------- ---------------------------- .DATE---------------------------------------------- ADDITIONAL COMMENTS---------------------- ------ --------------------------------------------------- ----------------- ------ --------------`------------------------------------------------------------------------------------------------------------------ e -- - - Final Inspection bY: � t;. !� �"h.. �'if[ "" Date , 7 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M