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FOR OFFICE USE: r .. ' .. APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ------------ - ----------------------------------- (Complete -- -- (Complete in Triplicate) Permit No._7.7_-_ ---- -------------------------------------- _ Date Issued__5.." -` � --••---'----- --- I--------------------------- 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: JOB, ADDRESS/ OCATION_,-,.. -3 -----------C - e-_-/- _ iG- - --- -------------------CENSUS TRACT --------------- Owner's Name--- ------- --------------------------- ----------- ----�--- Phone ---- --------- -----•----�-- � Address---------3- ..7 e GCJJIr?/� ._/,�f1C,- ------- ----- - -C it y ..�1_ ------------------ _ I .. P -- zi � = '----- p �� Contractor's Name-------- -- --- - ----- - ---License # ----------Phone-:T7q= .44. Installation will serve:'" Residence 0--Apartment House.❑ Commercial ❑ Trailer Court. ❑ r Motel ❑ Other--------- ---------------- Number of living units;-._!/.- Number of bedrooms_ ® ------------ --- Garbage Grinder-. --_-._---Lot Size--------.-/0 t4 ee------_-- Water Supply: Public System and name-------------------------- Private ©� Character of soil to a depth of 3 feet: Sand ❑ ,Silt❑ Clay ❑ , Peat❑ Sandy-Loam Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Material-..-- --..If yes, type------------- ----.--- t (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 seepage pit permitted if public sewer is available within 200 feet,) �! # PACKAGE TREATMENT [J" SEPTIC TANK [ ] Size------- �0��__-4� 6 WWW -------------------------------- --------Liquid 6 -- Capacity�l` 4d--------Type-410't/C*'F ----- - - No. Com artments_ _- `j Distance to.nearest: Well-----94_----------- Foundation_=- d-----------------Prop. Line------.--------.---.- LEACHING LINE [ ] No, of Lines----_S----- .Length of each lihe,_-+.7Q_�-------------- .Total Length.;- Ja N ----------------- ?D' Box------------Type Filter Material--------------------Depth Filter Material-------------------,------------------ -----------,---._---' ,r 9/ - . i � ,Distance to nearest: Well---------------- -----------Foundation.-.. _ ___--------- --Property Line--_,:5 ------------------_------ SE T [ ] Depth----;-----_'----Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No i <; Water Table Depth - =-------------- Rock Size ,Distance to nearest: Well----- --------------------------------.---Foundation Prop, Line REPAIR/ADDITION (Prev!Sanitation Permit#-------------------------------------- -- _--___1 1 ; - -------- -.Date-- ---- -----�-- - ----- ----- Septic Tank (Spec ify;Req uirements)------- ----------- ------=---------------- --------------------------- ---- 1 t Disposal Field (Specify Requirements)---------- -- ------- -----------:------=--- ------ ---------------------- ----------------------------------------------- ----------------------------------------- ------------------------------------------------ --------------------------------------- ----- i (Draw existing and required addition on reverse side) I hereby certify that I h-e prepared this.application and that the`work well be done in accordance with-Son 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: e "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as , to become sub' t to Workman's om ensation laws of California." Signed-- -------- - _ 1 - ------ y ' ` -�'— Owner BY '----------------------------------- -------------- --- ----------Title--------------------------- 1 (If other than owner) p FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_____ DATE -_- .- ._ . „r ------ - S �i DIVISION OF LAND NUMBER DATE---------- ----- - ---- ADDITIONAL COMMENTS-_�? /Jri G --------------------------------------------... � --------------------------------------- Final Inspection by. -- ---------- --- ---------------- --------------- ------------Date----- ------ EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M