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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 77_ ----4 �---------------- ----------------------- (Complete in Triplicate) Permit No--------------- --- --- .---------------------------- 3777 --------- Date Issued------------------ -_---------_-------------------------------------------- This Permit Expires I 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .. --------------------- ` ----------.CENSUS TRACT. ., l C'��t,C.- `' --------------- ----------- ----===---------------------- ----- -- :-Phone ---------------r �-. Owner's Name.Z Address.------- ------Cit - w- ----------- --- Zi ., ------ e- r �fContractors Nam - --- --•-- - , --------- ----- cense - _S r_ -----------Phone _� Installation will'serve: Residence 0-y'Apartment House.❑ Commercial ❑ Trailer Court ❑ ... .y Motel ❑ Other- ---------------------- - ~7 1. � Number of living units: of bedrooms. ----Garbea Grinder Size -.- -:� Water Supply: Public System and name-- and 1 'Sit a Clay peat _____________ ____ __ _ Private ; -- -.v- -=--=-- = ='-�' =--- Character of soil to a depth of 3 feet. S ❑ ❑ y ❑ ❑ Sandy Loam ❑ Clay Loam ' Hardpan Adobe Fill Material__.----.- p ❑ ❑ ---If yes, type-'-=`--------------- '- ---- ' f - i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placea 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 ------------------------N - .... •Ca acit ..W I1.�-----'-- --------------Material----Foundation----No--Co p. s ----------=-----•- t Distance to nearest., e F -art Prop. P Y-- - - ----- YP. •, Line------------------ ------ LEACHING - -LEACHING LINE { ] No, of Lines-.-_-- .-------_-.- _Length of each line---------------_---.----.----.Total Length --------------------------------------- 'D' ---_ 'D' Box------------Type Filter Material---------------------Depth Filter Material --------`- ----.-------I---------------.------------------- iDistance to nearest: Well.--- -----------------------Foundation-----------------------------Proper Property,Line' SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- ,- Rock'Filled Yes E] No Water Table Depth--------------------------------------=--------------:--Rock Size---- --- - ---------------- -------------- Distance to nearest: Well------------------------------- ------------Foundation---------_------ ----_ - Prop, Line-_---_-------.----.------ REPAIR/ADDITION (Prev:Sanitation Permit#----------------------------------------------------Date---------------.----- ----------------1 Septic Tank (Specify Requirements)-----------------------------------------------_--_.. ----------------- ----- ----------------------------------_------_-- ------ Disposal Field {Specify Requirements} 1 �- '`'.' .l.l� '------- -----------� -� ��'" ---------- } --------------------------------------------------------------------- ----------------------------------------------------------'----------------------•-------------=--------`---1----------------------------- --- ----- -----'--- -------------------------- ----- -------------------------------------- ---------------------------------------------- (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 Rules and Regulations of'the San Joaquin-.Local Health District. Home owner or licensed agents signature certifies the following: 1 ? "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." - d n � / 1 Signed.- - - 1 .Owner �r sl` l�� Title-- �--- - - - -----------_----- By E - : (If other than owner) FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY_= l ------ ------ -- -- - = DATE. = = DIVISION OF LAND NUMBER.------------------ --.-...------DATE---------------------- ADDITIONAL COMMENTS-------- ---- ------ --------------------------------- ---------=------------- ------ ------------------- ----- - = ' � ----- --------- = ------------- ------------------ f ----------------------------------- -------------------------------- --- Final Inspection by:----- - Date..-: .. � --- ----- ------- -- E14 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 R /7e 3M