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FOR OFFICE USE: �` - FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y� (Complete in Triplicate) Permit No_______________________ r 1 ( t Date Issued./%--__--- 7 ----This Permit Expires•1 Year From Date Issued,.- Application is hereby made to the San Jo`aquin.Local HealtAistricf for-a permit to construct and install the work herein described, This application is made incompliance'with County Ordinance No. 549 and existing Rules and Regulations:. JOB ADDRESS/LOCATION O ----- ---- ---- -- Owner's Name .2 CENSUS.TRACT_ =/x�l ---= ------------- ------ --- --- - 1 . i - -,- Pho ----- ---- Address-- --- ------ = = Atiw e------- --- ---- ------------ ----- city�Tc�G 'y-- . ------------Zi --------------�-/------- Contractor's Name--. r }. 1en _Y--R,A-v .. License # f.. --Phone nT�_------4.0 Installation will serve: ' ResidenceX--Apartment House []—Commercial El—Trailer Court.❑ .. ..,. Motel ❑ Other--------- =---------------------------------- -416 0 I ' Number of living units:-------- of bedrooms__._2-_ _Garbage Grinder_.__ _ ;____Lot Size..`_a__ ____..________________________ r- i Water Supply: Public System and name------ _: ti =--------------=----------- - Q. �Wt r -------s---------------- -------- to ❑ Character of soil to a depth`Of 3 feet: Sand ❑` .Silt r] *Clay ❑ Peat❑ Sandy Loa� o 0 Clay Loom Hard an ..�r—Adobe �" "Fila Material. lf, es,,t a--- + (Plot plan, showing size of lot, location OTsystemin relation,tal.wells, buildings, etc. must be placed on reverse side.[ NEW INSTALLATION: (No septic tanktor*seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT . SEPTIC TANKQ � tea,MM �. -_-----=----- --- ___________________ Liquid Depth Compartments---F....... --- -�--:--'Caacity: ; - � i 1 " ff Distance.,to nearest:.Well,_�' _Q_N:I _._.: -------------------Foundation-- --=--------.Prop. LEACHING LINE [jQ No. of,Lines Length ofxeach line.---/Q _ ___________ Tofial Length. .._______._a__,_._____. . D'IBox TypeyFilterhMat( i _Depth-FiEter l tfrral ' :--- -. -------- 1 to nearest``Well _�`� _____ __�____foundation___� __- .Property Line_.,_._�_�----------------- Distance . SEEPAGE PIT [ _ Depth_ .__Diameter..e3.-_____Number___ ,,f ____ _______________ Rock Filled Yes A[ No [ p x 3 Water Table be th._ '- '�- - --------------- ' Rock Size _ ! ! 1 . �.. Disfance.to nearest:Welf__ '_�VC�-_ l_e'___'________________Foundation_.s___ _---------------Prop. Line____._��____._.___.._° REPAIR/ADDITION (Prev. Sanitation Permit `----`------------ ---`-i_____ --------__-_Date-----------_------------------- -- ) f Septic Tank (Specify.Requirements)---- _ -_.. - i J - = = -==--------------=---------------------------------- Dis,posal Field (Specify Requirements)-- --.: -.-.-- ___._� �---r - -y, ------------------------------------------------------- - ------ -- - ------------- ---------------- - ----------- ---------------------- �:: _ • h .F (Draw existing and required addit'ion,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 Regulation§ of the San Joaquin Local Health District. Home owner or licensed agents r signature certifies the following: ' t C+ "1 certify that in the'performance of the-work for which this i'Aermit is issued, :I shall not employ any person in such manner as to become subject to Workman's Compensation- lows of California." ' Y Signed.. -i._1C_I.aP-_P-_t_3_t-f _.:_ .. wner. ..: __. (if"other than 'owne ��` •� t r R tR FR 46ARTMENT USE ONLY,lo APPLICATION ACCEPTED BY------------ --------- ----------------=-=---------------------------- --- -. __._DATE.-----k ------= ------=--- r DIVISION OF LAND NUMBER:---- ¢ ----= DATE------------------------------------------------- ADDITIONAL -- ---- =-------------------------- �- ADDITIONAL COMMENTS. C == 'f -. I�.----------�----= f/ /4 77•----1/<------------------------------------------ I . ----------------=---------------------------- --------'--------``-------- = ---------------------------------- -- -------- ----- -- ------- - --- -----------------------------------------------:---------------------------- -------------------------------------------------------=-------------------- ------------=--------------------=--------------------------------- ---------------------- ----------- -------------------------------------- ------- - - ------ -'-------------------------------- -------------------- --------------------------- Inspection bY: _ __� --- ----- - -- �.�..- "..�"' -= 77 -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 3M F&S 21577 RFV. 7/76