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FORR OFFICE USE; FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- -------- ---- ------- Permit No_.7.7' 7� (Complete in Triplicate) ---- ----------------------------------------- Date Issued--- ------------ -------------------------------------------- ssued___._-_-------_.--__________________________________________ This Permit Expires 1 Year From Date Issued 3 000e ...5., Assam} +>�c�J✓ - Application is ereby made to the gan 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. 5 and existing Rulers and Regulations: JOB ADDRESS/LOCATION. l��c.P �1_.:_." avO,�r�Ssa l dam_`-ENSUJS TRACT---------------------------70 / k A a- +2 .3------- --=- -- ---..Phone----- ---- Owner's Name.- -- -- ` [ Address. `v ,�CSC� -t - YIQG't�'7fil � ": zip---.-Cit �!_G' �1 .. _� ` 04 p--p- r__f- Vj �N� License�k $ V Plio T' j Contractor's me -- --- -. -- ne-_ 6-P0 '---- Instal lcition,will'sarve: Residence �, Apartment House.❑ Commertial �] Trailer Court ❑ Motel ❑ Other-- ` i' == . }..-._ ., k a> 4 Number`of bedroo .... _._.___Gafb a Grindar ._Lot Size __ _ L� Number of living units:--- gf- -. -.--- �, Water Supply: Public System-and name-----------=--- -. - -- i ---- ------ .. --- -=P ivatej€ [g' Character of soil to a depth of 3 feet: Sand ❑ ' Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam ❑ t Hardpan ❑ ; Adobe E]:-!-Fill yes, type (Plot plan, showing size of lot, location of s.ystern in relation to wells, buildings, etc. must be laced on reverse side.) NEW -INSTALLATION: -[(Nosepti� tank'or seepage ,pit permitted if public sewer is available within-200 feet,) ] o - r 0. : PACKAGE TREATMENT [ ] SEPTIC/ ANK �Q � �Size_ i,��_�-1�. "__Liquid Depth,!-?;5 Capacity-�_2?_�------Typgj�c _ i No.-Compartments_.:__ ...r'-�._ Material � -----=- ------ ' ---- 1 d . � .. . : .. Distance to nearest: Vllel!_.�_��d__!____._____ -•—Foundation_.--�-�4.�_-�-�.Prop.-.Line ._.�__:.__.!__,_�. ! LEACHING LINE [ No, bf Lines__. _�_ /--.'Length o �� f F <. `�'�'___-1- .len f eac lino---� --------- ---.:-----�----.Total Length.-----��-�----------- -"=---�� D' Box--:------- Type Filter Material Depth�i.iter MatePial Distance to nearest: Wel l__-_10------------- oundafion__/_, _ ----------Property Line----------------------------- 4. ` R Water Table Depth = ----- ------------ Rock Size------------ No SEEPAGE PIT [ ] De th---- ----------Diameter------- --- - :k - Number -=------'--------- t _ _ Rock i es Distance to nearest:Well_________-------------------- --------------Foundation------- ----------Prop. _ _ a _ Line_---_ --` - REPAIR/ADDITION•(Prev: Saritation-Permit# _______ _________ _____ . Date_ = a 4, I � F I Septic Tank (Specify Requirements) -°--------------==- ----=-----.----=------ .-------------------------------- ------------- --------- Disposal Field (Specify Requirements)-. ` ----------- -------------------------- ---------------------------------- , i I j --- -- - --- -- - ---- 4 � { * ._ _ ___ - -- - - -- __ -- ____ ------------- __ '. __- _ __--- ___ --_--_-_--•---._---__ ---- --------------------------------- ' (Dr zisting 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 I Ordinances,' State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the Following: I "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 subj et to Workman's Co ensotion-,laws of California." Signed_. ------------ ----- :;. = BY- -------------Y-------------------------=-----------=------------- Title_ sr✓j T _.. (If other than owner) '"� i FOR-DEPARTNT USE ONLY . , APPLICATION ACCEPTED BY---:__- `------------ ----- _-_A___DATE.' = DIVISION OF LAND NUMBER.------=------ --- -------`--------- -- ---------- ------- .......DATE---------------------------------------------------- ADDITIONAL ---------------=--------------- _ .. - ADDITIONAL COMMENTS'........... - ---- ---------------------------------------- - --------------------------------- ----------------- -------.------------------- ------------------------- ----- -_------_------ --------------------- � ----- ----------------- ----------------°--------------------------=----------------------------------------------- -----=----------- ------------ - -------- ------------------------___---- -- ------- --------------- __ --------- ___ _ ______ ___ ._Y _____--.--. - 1=.final Ins ectian b �/� F&S 21677 REV. 7/78 3M ------------- ---Date--- -- -------- p - ` = _----- -- ---- -- --- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT