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FOR'OFFICE USE: FOR OFFICE,USE: <br /> r' APPLICATION FOR SANITATION PERMIT i <br /> (Complete in Triplicate) <br /> Permit No. 77-- <br /> ------------------------ -------------------------- <br /> Date Issued....?-/3- 14 <br /> --------- ---------- ----------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the SariJoaquinLocal Heath District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County-Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --. _-- . ,------------------ '' �Y ids ----------- ____CENSUS TRACT------ <br /> Owner's Na!me...... Y/�riV-=�1�:------ 5;_4.V ------------------------- --------- --- ----------------------------Phone.-- --- -------------- <br /> Address - - - --. �Y fv ."l5lG ]�.eN_..-City /��e�---- ----- Zip_ i <br /> ----- G <br /> Contractor's Name---._ - !✓ dZ�­- - -------------- <br /> -------License ------Phone - - --- <br /> t. <br /> installation will serve: } Residence ❑; Apartment House' <br /> ❑ Commercial E] Trailer Court ❑ <br /> li.._.. ._... Motel F- Other-_: i41_ ' __.r�A -- <br /> Number of-living.units:---------'------Num'ber.of.bedrooms',.__ _ --Garbage Grinder.: -LotiSize � ....................... .-._. <br /> Water Supply: Public System_and'name----------------------------- - --- -----:----------------------------------- --------------------- <br /> -- ----- - --------Private❑ <br /> Character of soil two a depth of 3 feet�;�Sa�d �Silt Clay ❑ � Peat ❑ Sandy Loam`❑ lay Loam ❑ t <br /> p ❑�C� Y <br /> Hardpan Adobe ❑ F;IIi Material....____._..If yes, type --- -*.-_-.-- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: '(No'septic tank or seepage pit permitted •if public_s_e_wert:available within 200 feet,) <br /> I PACKAGE TREATMENT- ['] = SEPTIC TANK ] ] Size-------------------------- �-----------------------------Liquid Depth._ -.---._---_ <br /> ] a. Capacity4 '4CTYPe f' Pe��STMatariaLG_S7_ :C Compartments.-c-A----------------------- --- <br /> iDistance to.nearest: Well-- .___.! ------ Foundation--_"_:-.----- - -----Prop. Line--------------- ------------ - <br /> I �- t <br /> LEACHING LINE i j ] No. of Lines------ -- -- --------------Lengthtiof earl line------ _______________.7otal Length -.-AV <br /> ength _.__ ®__ <br />` D' Box -----__.-..T- +e Filter Material:y�e'CDepth----- Filter Material___ A2 �r_-.-.___.__ ---_ ______________ <br /> ) r <br /> .. .;.... ,FYI? - . _ .._ � ... - --�- <br /> "__._-_-_.-Foundation.--_._ __Pro ert Line_________ _____________ <br /> Distance to nearest: Well--------- ----- Property --------- <br /> SEEPAGE PIT Depth___-'- --_---Diameter.. _ Number______________/______1- Rock Filled Yes ] No❑ <br /> r Water Table Depth. -------- --------;i -Rock Size-------=---------------------------------------- <br /> r. <br /> Distprlce-to_near-est:-Well_—_—T t :_._Foundation-------- ----------- Prop. Line------------- ' 77 <br /> I REPAIR/ADDITION (Prev. S a:itation Permit#------------------1------_ "-� � � <br /> --- ------=---- - � Date------------------------------------------------- <br /> ----------- <br /> -----:---- ------ =--- --------------- -- ) <br /> Septic Tank (Specify.Requirements)----- .._ =- - = -' = ----=--------------------------------------- - <br /> Disposal Field (Specify Requiiements)---------------------- - ------------------------:------------------------------------------ ----'------------------------------ :- <br /> t -- -- - ----------------- <br /> ----------------------- -------------- ------- ---------------------------- -- ------- ----------------------------- <br /> (Draw existing 8nd required addition on reverse side) A.. <br /> I hereby certify-that I have prepared this application and that the work will be done in accordance with San-Joaquin County <br /> Ordinances, Stale_-Laws,.and--Rules-4:and-Regulations of the San Joaquin Local Health District, Home owner or licensed agents a <br /> signature certifies the following: 1 r <br /> "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 <br />` to become subject to Workman's Compensation laws of California.". <br /> x Signedi.. � ' r'O / -----------,:-, -- 0v✓ner <br /> BY Title . : _ :_-- ; <br /> . <br /> P :o a w o er) <br /> j 'FOR DEPARTMENT USE ONLY" + ; <br /> APPLICATION ACCEPTED BY - -----------=---- ---DAT E.__. v = <br /> DIVISION OF LAND NUMBER ------------------------------- DATE .. <br /> ADDITIONAL COMMENTS- ---._4w. ------=-------------------- ---- ---------------- <br /> t <br /> -------------------------- -------------------------- -- --- -- --------------------------------------.------------------ --- - -- --.--------------.--------- <br /> ------------------------ <br /> --- -- <br /> -FinII`Inspectior b?.;---•-- �_��f%�L Dafe�-:r`�=��`=�- <br /> EH 13 24 SAN JOAQUIN LOCAL,HEALTH;DISTRICT N. F&5 21677 REV, 7/76 3M <br /> 7 ry <br />