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FOR OFFICE USE: FOR OFFICE USE': APPLICATION FOR SANITATION PERMIT ^ Permit No..--77=-��"-� ---- -------------------------- '�5 .. w h (Complete in Triplicate) _w.�. 77 Date ------------------ ------------- --•---------- ------ ------- ---------------- This Permit Expires 1 Year From Date Issued Application is hereby made torch San Joaquin Local Health District for a permit xist ng Rultruct and install the es and Regulations: work herein described This application is made in compliance �. a -------- CENSUS TRACT. ------------------ ". JOB ADDRESS/LOCA N._,,-. ------ ----------- ----------- Zip ----- -= Owner's Name----' -_'. _..< ip ------------------ r O a aa C' �- Address------- ------------rte+ r .. License er;S �1 4 -------------------------- contractor's = - _ one- Ph -: �J # 7 3 Ph Name--- fi`' ='r- _. - Installation will serve: `� Residence Apartment House.❑ Commercial ❑ Trailer Court. ❑ f sR. t Motel ❑ Other `--"=--= -------- ,? - --�- -- ----- ----------------- -' Number of livingunits:.... ---�-__Number of bedrooms.--------Garbage Grinder----.-.-----Lot Size._ -_Q rPrivate Water Supply: Public System and name------------------ ----------- --- -- - - -- -------------------------------- -- -.- Character of soil to a depth of 3 feet: Sand.Q =Silt❑ Clay 0_- Peat ❑ Sandy Loam Clay loam El �. . Hardpan Adobe ❑ Fill Material_.-..-. If yes, type--------------------------------- ( plan,`lan, 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 i� available within 200 feet,) y�(� -------------------------------- -- t-------------------Liquid Depth t-----f-- --------------- , PACKAGE TREATMENT [ ] SEPTIC TANK S�izfe -- ----- ---- - 0 D�__--_T e /;!? F'f -: •-Material_. No. Compartments = Capacity/ -. Type Pro Line---- -- ------------ ---- ; ----------------- Distance to nearest: Well..- .----- •'- = Foundation_-- .-----==-- P LEACHING LINE {[H�. N°. of Lines--3 :- '-'-:=`'Length of-each line:_.., r y0_ -�_ _,Total Length.--:_�-�-� . A $ _ _. ----_ - -- L D' Box__I_------Type Filter Moterial_SCo�?--Depth Filter Material- Line n__. _. Property _ , Distance�to nearest: Well- -_ __ .Foundatt' •� .� NO' Rock FiHed 1(�s 0 SEEPAGE PIT Depth--a;------Diameter. ------------- ----Number---: _ .. Water Table DepthDQ ---=-- -- Rock Size ------------------------------ f ro t Distance to nearest Well-_--./�d:d - --------------- ---Foundation_------- -----------Prop. Line--------------------- ----- --Date------------- ----------------------------} REPAIR/ADDITION (Prev. Sanitation Permit#-__------------------ ---;. ---------------------- '-- ------------------------------------------------ Septic Tank (Specify Requirements)_____________ __________ -------- ---- Disposal Field (Specify Requ,irements)------------- -- - ----------==--' F. .;' _ _ ----- - f ,. - -=------------ -------------------------------- E ---- ------- -- ------'----'-------------------------------------------------.. ------- --- - --------- -------------- ------------------------------ ----------------- :. (Draw existing and required addifiion 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 ' s and Regulations of the San Joaquin Local Health District. Hosie owner or licensed agents Ordinances, State taws, and Rule signature certifies the following: : "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 je t to Wo an's�Com�Compensation laws of California." ~ r� ^. ----- ------ Owner Signed - ------------ -- ------------------------ Title. . ...... (If other than'owrIer) t PARTMENT USE ONLY L �Ls APPLICATION ACCEPTED B ------ -- - -- ---- - ----------------- DATE. --------------- ----------- DAT DIVISION OF LAND NUMBER----------------------- ------------------ ADDITIONAL COMMENTS------------------- -------- - � -- ---------------- --- - ------- ------- -------- ---- � ----------- � - - -- -- - -- ---Date. ------------------- ---------------------------------- Final ------ --Final Inspection b p y:------------- ----"- - F&5 21677 REV. 7176 3m EH 13 24 SAN JOAQUIN L AL HEALTH DISTRICT