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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.---77 -7� (Complete in Triplicate) ; --------------------------------- ----------------------- Date Issued-_,F- --- 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 Ordionce No. 549 and existing Rules and Regulations:, JOB ADDRESS/LOCATIO L-- `�~ r ---' '------ CENSUS TRACT Name ss. AGS B - " ------ Owner's ' - Phone------ ---------- --------- -- ---- �f,'� ---Ci �' -----Zi ------ ---------- ' Address- --- -------------- ..( - -'--- .-..._ ,-.- tY ' -' p _ j Contractor's Name-------------Ti a--�- --- -<-- ----- - -- License #M_20 ---.Phone--�X�_---�/�<-. i Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 4 Motel ❑ Otther------- -- --------------------'---- --------- Number of living units:----------------Number of bedrooms ��.p-.-[------Garb ge rindtr_______---_Lot Size------.__,_------------------------------_-------_------.- Private Water Supply: Public System and name------------------L.��-------��-- --L�r --'- --:-------.--------------------------------------------------- ❑ Character of soil to a depth of 3 feet: Sand ❑ silt? Clay ❑ Peat I] Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material---------__If yes, type------------ ----------_-_.____ (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,) 0 PACKAGE TREATMENT [ ] . SEPTIC TANK K Siz -------------------------------------------------------------Liquid Depth----------------------:---- Capacity-l! --------Type'--'- /P --Material----------= ---------No: Compa•rtments------------------:2 _ Distance to nearest: Well---------- ---------------------------Foundation------ 1..,.-_.----------Prop. Line------------------------- LEACHING LINE [ ] No. of Lines----=-- ---------------------- Length ea line---------------'--------------..Total Lemo�n}gtth._ 'D' Box--L---..__Type Filter Material---------- �-.--------------------------------- / ..Depth Filter Material ------------------ ----------------- •. --- a Distance to nearest: Well---------------------- -----Foundation----------------------------Property Line-----------------------------------. SEEPAGE PIT [ ] Depth.__,.__._ Diameter__-----------------Number---- ------------____.---------- Rock Filled Yes ❑ No Water Table Depth ------------------ _--- - Rock Size------------------------------------------------ Distance to nearest: Well---------------------------------------r--Foundation---------------.----__--.Prop. Line-----------------------1-- REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------------------=-=-------Date--------------.--------..---------------------1 Septic Tank (Specify Requirements)--------------- ---. Disposal Field (Specify Requirements) D{ Gfk --- -l`---------- 1 ------------------------ ------------------------ - --- ---------------------- ----------------- ----- ------------------------------------------------------------- -------------------------------------------------------------- -------------------- ------------------------------- (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: k "I certify that i the pert r a of the work f _r'which. is permit is issued, I shall not employ any person in such manner as to become su ct to W rpen ti a California." Signed---------- ----- Owner BY ------------------------------------- --------------------------------------- --------------- 'Title " . ---------------------- ----- ------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY " ----------- -------- DATE p� � DIVISION OF LAND NUMBER. - ------- -- DATE. ADDITION OMMENT - ,� ; - - - _ ---------- ---- 'u ---- X221 .tib �_ �-. ----------�1 -- ---- --- ' ------- ------- ------ --' --- -- �'' Date = /�� Finale Inspection by " r _ --------------------------------- ------------------------------ - f ' EH 13 24 SAN JOAQUIN LOCAL'HEALTH DISTRICT res 21677 REV, 776 3M J - y.