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�FFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- ° 7 -=-(�- - (Complete in Triplicate) Permit No... ��!_ Date Issued--9-__7..-7,7 -------------------------------------------------- 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. 549 and existing Rules and Regulations: 1 40 4 JOB ADDRESS/LOCATIONf a ------W ------ ------------------ CENSUS TRACT:.::__ -- 3z ".AOwner's Name.------;;73`''►± Ov -----------=------[--------------- -----------------------------------------------------------------Phone ------------------------- Address-.--------------- ddress-.---------------$4'j -------------------------------- ---- --------- ------------------Ci --Zi 4 ----------License #--- ---- -- - —----------Phone----------- ---------------- Installation -- ' Contractor's Name - N-��------------------�� ----------------- ---- - -- '-------- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ 5 t� Motel ❑ Other._- Number of livin units:w _R . ` Numbei.of bedrooms___ _ __GarbageGrinde .__ __Lot Size____-__.SS'__x_ -.---. -: .-_ Water Supply: Public System and name_------__ =p!>?+ --_.---Ll1rt. r _________________Private Character of soil to a depth of;3 feet: Sand ❑? Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ CIayr o ❑ Hardpan ❑ Adobe E? Fill Material___------._.If yes, type-------------------------_----i �. (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 -s"eepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ¢4Size-------- _. --_-__'_ ` �""_--� ____+Liquid Depth ---_--- Capacity---------------------Type----------------------Material--------------------------No. Compartments.--------j- ---- Distance to nearest:.Wel.l—__.--__-------------------_-------__Foundation-----------------------L.Prop. Line ___._.__--- LEACHING LINE [ ] No. of Lines-------------I----- Length of each line______________-96?----------Total Length:__., _! -------------- ------- 'D' Box-----Z_Type Filter Material--- 92c -_.Depth Filter Material--------- - <- ___`_ ___---------------------- Distdnca to nearest: Well..__,._-1 A---:---__-Foundation-------- -S_.f-----------Property Line-------t ----------------- SEEPAGE PIT [ ] Depth._.__ .5-_-__Diameter____ _3 ____-Number___-______-------------- ---- Rock Fillet! Yes No ❑ Water Table Depth------------1e.4 Rock Size, A-11 R Distance to nearest: WelL.________N11-----------------------Founanon __ _--&S7------------Prop, line----5------ - - REPAIR/ADDITION (Prev. Sanitation Permit#----------- ---------------------------------------Date--------------------------------------I------- ` SepticTank (Specify Requirements)--------------------------- ----------------------------------------------------------------------------------------------- -------------------------- --- DisposalField (Specify Requirements)---------------------- ------------------------------------------------------------------------------- ----------------- ----------- -- ------------------- ----------------------- -------------------t----------------------- ?I ------------------------------------------- - - ----------- -------------------------------------------------------------------- ______________ ____-------______._____----.----._ _..__.____.__.___.____.___.___..____.____€__F_.____.________ (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: , "I certify that in the performance of the work forwrhich this permit is issued, I shall not employ any person in such manner as to become_,soject to Workman's ompensation laws of California." Signed ` ----- i` Owner By------- ---- ------------------------------- - ----------------t------------------------Title-... (If other than owner)_ _—FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ - F DATE 7-------------------- DIVISION OF LAND NUMBER --------- -------- --------- -------------- DATE.------ ---------------------------------------- ADDITIONAL COMMENTS._---_----_ Gk------/U'Zv-77 .L OXY ------ ------------------------------------------------------------------------------------------------ ---------------------------------- -------- ------------------------------------ ------------------------------- ------------------------ ------ --------------------------- -------------------------------------------- f ------ --------------------------------- ----------------- ----- -- --- - -- ---- -- ------ - Final Inspection by�--- . ----- -------------------------------------------------------------------------------Date----- J( EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M