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V,_ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: JJ �� Permit No._77��3:3 1�', (Complete in Triplicate} -------------- 7 Date Issued. -�-___._ ---------------------------------_ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for_aW-permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and exis 'ng Rules and Regulations: JY SIC ` - - -`--- ---- -- -------- CENSUS TRACT..----- -• ---- - - -----JOB ADDRESS/LOCAT;ON • $ Owner's Namelf grR,- - �e �._-.,_ -,-.._ _ ----------------- ----------------------------Phon----------------- . --- - -.---------- -� - [ K�- 1P.�� -" = City ' a�sl ..-- ----------Zip----/--- Address ----- - = r ,5 ' �` '' ' = ±�_fZ L�k `F"' _ ,l- Phone-51 /�nr �rr _ N ©xCS- - - +�lr— License # �4 - Contractor s Name. a ` 1 r otel Other------------ Ac, _---.. -_# _ "fes;�. _ Installation will serv� tDResidence� Apartment House_,❑ Commercial ❑ Trailer Court ❑ ;! j Number of living units:. _- %Number•,of bedrooms.--,Garbage Grinder=,-----------Lot Size__._f� �'eR��------------ -----•----------- -- Water Supply: Public System and:name =------ --------------------- -------------------------------------------------------------- - ----Private` r,!• ~ Character of soil to a depth of 3 feet: SandE]/ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 1pt r Harclpar� , Adobe Fill Nlateria,l-_ '--.-_.If yes, type-------------------------------- a -----_ - --.- ----. i, (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc. must be plated 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--------------------------------------------- --1. ---------.Liquid Depth.------- ------- -- Capacity --'------------------Type-----------------------Material, ------ -----------------No. Compartments---------------- Distance to nearest: Well--------- -- 1------------ --'Foundation LEACHING --=-._..Prop. Line---.---------------- ----� '� ------ E LEACHING LINE [ ] No. of Lines_�-------------------- Length of each li�ef�th`f Filter Maferial-Total Length---- --------------- -- _---- D Box-------_ -Type Filter Material_-. .- p Distanceto nearest: Well----------------------- ----Foundation--__°` '------------------ ----Property Line------------------------------ !.. . s s fSEEPAGE PIT [ ] Depth________________Diameter._;---_--.---__;____Number-___.___----- i Rock Filled Yes ❑ No ❑ Water Table Depth Rock Size---- I------------------------------------------ s Distance to nearest: Well------------------------r-_-„------------Foundation---.---- _-- --:- Prop. Line--------- ---------------- REPAIR/ADDITION (Prev;Sanitation Permit# ---------------------=----------------------Date---------------------------------------------- Septic -----Se tic Tank (Specify Requirements)------ ------ - -------- 0----------- -------------- ) ' - ---- ------- - - ® --- � Disposal Field (Specify Requirements)- pplerner --------- --------`�---------I----------------------------=------ ---------- ---------- ------ ----------------------------------------------- _ (Draw existing and'required addition on reverse side) t I hereby certify that I have prepared this application and tha the work will be done in accordance with San Joaquin County' Ordinances, State Laws, and Rules 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 becojZe sub' ct orkman's Com nsation laws of California." Sign r R_2iSl --`1` © IAC'---------Owner BY - = - Ti tle_T�ef777D (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY -- - -- -------------- --- - ------------------------------------------- DATE. DIVISION OF LAND NUMBER------------ ------- - -----------DATE -------------------- ADDITIONALCOMMENTS------------------ --------- ------------------- ------------------- -------------------------------.. ----------------- ------------- ------------------------------------------------------------------------------------------------------------------- ------------------- -- - - ---------- -- -------- - ------- ----- -=-------------------------- ---------------------------------------------------------- ---------- '� - ------ -- Final Inspection by------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV 7/76 3M