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FOR Or=FiU USE: FOR OFFICE USE: 4' APPLIICATION FOR SANITATION PERMIT 77 — /� --------------- ------ ----------- - Permit No..------ - --------- (Complete in Triplicate) . Date Issued---6_`2-7-17 _______________'___._......_.-------------.___._.__-._._. This Permit Expires 1 Year From Date Issued Application is hereby-made-to-the'3an-Jo-aiquin"tocol"'wealth Disfricf for a permit to construct and install the work herein described. This application is made in compl'ance with County Ordinance No. 549 and existing Rules�.and Regulations: _ ..y _ J�B AD RESS/LO11=P� _ _:.-_ r--- -- ?5'0 73EE 2.O � NSUSTRAC ' T_ Owner's Name-'---.-.- --- one Address-------V411f _ -- t s Name . - -------------- C ty -Zip-- I nContractor �" � --- Lice" one Installation will.serve: T Residence _ Ap artment-House. Commercial ❑ Trailer Court ❑ i - •� �_ ,...,F,.....t......jvMotel�❑ ( :.Other : Number of.living units:-. __ _ _ ___ Number.of,bedrooms __Garbage_Grinde�r� -_._Lot:Size_____ -,. Water Supply: Pubic System` and name-_ . -------------- _ �- -------.._.-._-_--_ ,.f ' — ---- Private9c[r�_ F" a depth of 3 feet: Sand ❑ 'Silt 0 Clay ❑ Peaty[]! Sandy Loam ❑ -Clay Lop`_m ❑ Hardpan Adobe ❑ Fill Material__3__ _._ _If yes, type__________________ }ratter o soil to (Plot plan, showing size of lot, location of system in relation'`to'wells,tbuildings, etc. must be placed on reverse side.) ' NEW INSTALLATION: (No septic tank or see 3ge pit permitted if publ c'sewer is available within 204 feet,} ® f PACKAGE TREATMENT [ i y / [ ] SEPTIC TANK' Size ---- - ---------.Liquid Depth._ -------------- Capacity-- - -®--- Type - Material -:t�Z-c�•�@;:---,_ -No: Compartments---- 7�--------------'----i I t 4.,. Distance to nearest:.We11_:._4_ __-:,-- -------_--.'Eoundation,_,__..1-a- ----.Prop Line-------- ------ ---- :• ------ LEACHING LINE ,[ , No. of Lines.. _,___...-. _______________Length of-;each line--,__--._q_P__�=------Total Length _--- _ '_�-r--_---------- rI tt D' Box------------T Pe Filter Mate�r-ial__ Ss_ _<De th FIilfer M.a. terial---�--- I- r `u --------------------------------------------- Distance, - ------ -----Distance to nearest. Well___-___ h Foundation_"=f-U-F" _.Property Line-------_ SEEPAGE PIT i'[ ] Depth_.- �'S`kDiameter_ -----------N�umb er---_.____ 4 ] ---- --- ------ Rock Filled Yes �No ❑ r a Water Tpble.De th-'------`---- -ate__' Rock Size- -- E 1 � ' `Foundation- �._ Prop. Line---- REPAIR/ADDITION'(Prey. Sanitation Permit#W ` _ --•---------- '- `-'----------__'_:Dater ----�--5 ----=--=-- ----------------- ------------- Septic Tank (Specify Requirements)___________ .. t . _ �. Disposal F,,ield:(Specify Requirements)--------------=------- ----------- -:-- - -_------:----- : S ------ , -: ----------------------- =----------------------- ------------ -- --_-------=--------------------------------------- (Draw existing and,required addition on reverse side) ' I hereby certify that I have prepared this application ond-4ha't'tlie 'work will be done in accordance with San Joaquin County Ordinances, Sfate Laws, and Rules and Regulations of:the. San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: } a "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." . Owner- y .x .. - _ BY' = ------- - .. ,. - --------------------------------------- ' (If other than'.owner -------- ;9 FOR' EPARTMENT USE ONLY t APPLICATION ACCEPTED BY--------- ---- - -- -----" -- - --------------- ------------ -----DATE.-Z ------- DIVISION OF LAND NUMBER:-----¢----------------------_--- =- _ = - DATE { - { ADDITIONAL COMMENTS -----------------------------------------------------<--------------------------------- ------ ------- ------ ------------------ ------------ ----------- =-=--------------------=---- ------------- ------------ --------------------------------------------- -------------------------------- ---------------------------------- Final Inspection-by:__: -----------------'------- ---`-------------------- -----=----------- Date__L z ._.._... FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7/76 3M .