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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 77- z � -- <br />.............. ....................--•-•........I....... Permit No <br /> �� <br /> (Complete Triplicate} . ....................• <br /> .......................: ...................... . ( p 77 <br /> r Date Issued <br /> . ................... <br /> ..................�.......................... This Permit Expires 4 Year From Date Issued <br /> .......--.. , <br /> Application is�hereby made to the San Joaquin local Health District for a permit to constrict and Install the work herein <br /> described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulotlonss <br /> I <br /> _.. ......: ... R ............... <br /> / �P Y.... CENSUS TRACT .......................... <br /> JOB ADDRESS/LOCATION ........ ..�-.�.... <br /> Owner's Name <br /> .... �•nn ! . ... .......................................... y .Phon ..... <br /> Address <br /> ............................... .........................•----.. .............................. � ............_...------................ ... <br /> j <br /> Contractor's Name .._.,�+�c�A..l. �� .......................................License <br /> Installation will serves _;Residence❑Apartment House fl Commercial C1'railer Court <br /> TNj Motel p Other <br /> Number of living units:------------ Number of bedrooms ............Garbage Grinder ............ Lot Size ................................. <br /> Water Supply Public System and name .....--•---......•...................-----•---•-....._.....---..:.........................................PrIVcft <br /> Character of soil to a depth of 3 feet: Sand t3 Slit❑ Clay ❑ Peat❑ Sandy Loam Q day Loam ❑ <br /> fHardpan❑ Adobe 0 fill Materlal ............If yes,type.............. ............ <br /> !Piot plan, showing size of lot, location of system in relatlon to wells, buildings, atc.'must be'placed on reverse'side.) <br /> NEW INSTALLATION: (No septic tank or seepage'pit permitted If public sewer is available within 200 feet,) � <br /> PACKAGE TREATMENT ( ] r $EPTIC,TANK-f ] Size............................................ ` Uquid Depth .............. . ...0 . <br /> itCapacity .................... Type -- ....._...... Materlal.:..................... No. Compartments ..................... <br /> Distance to 'nearest: Well ............................... .Four+dation.....---••- :.:Prop. Line .....`.-...............� . <br /> .EACHING LINE { j No:~of lines . -- . .... Length of each -llno:�...� ...... Total•length ......... .{..,...,.... <br /> T 'D' Box ............ Type Filter Material'.......14E... �..Deptli Filter Materlal'{ . - :...' ,.............. <br /> Distance to nearests.Well'.,:.*:..........."` ,Foundation .............. :::., ,Property 11ne, . ..........,........ . <br /> SEEPAGE PIT { ) Depth Diameter _..... Number ..................... <br /> .Rock Filled Yes ❑ No ❑b <br /> ! Water Table Dep-th k :...................... ''...........' Rock Size ..:.......... <br /> Distance to nearest:IWeH ................... . ......Foundation' ................... Prop. Lina .....................REPAIR/ADDITION(Prov. Sanitation Permit ...... ...:......... ... ::.:.... Date ........::.:. .............. .I <br /> Septic Tank (Specify Requirements) .............. ..... ...... <br /> ..:�... ..................... ..................,...........Y <br /> Disnosal Field !Specify Requirements) ........�.w✓ .." .i�1�...�'.. ......................................................... <br /> ..:�.:ts�l ............ .... .---....--•--•................. <br /> ........... ^_..,................................... . V r._,_._.................-- :_:... . ..5.. ......__..._............._......,.... ................. <br /> " <br /> ......................................................... .. ......_.............. ..............................._..............__.. <br /> li (Draw existing and recluired addition on reverse'side) <br /> I hereby certify that I have prepared this application and that the work will be done in aecordana with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licew <br /> sed agents signature certifies the following: ,t ., <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 <br /> as to becomesubi ct ttYorkman's Compensation laws of California." <br /> Signed .... ' .,r.. l� ......................... :....... Owner <br />{ By ..... .....:....1i-•-------........._...._._..-----------•----------------........................---_. Title ..........................................................-.... ....: <br /> II DEPARTMENT E ONLY r <br /> APPLICATION ACCEPTED BY DATE ' 7..�..; <br /> BUILDING PERMIT ISSUED .....................................................--...... . <br /> :.. ....... . ........................DATE-::............................_-..-_-.................. <br /> ADDITIONAL!jCOMMENTS ...... -............................................... ......................................I............................................._.: -------- <br /> ii ..._..... ..... ........ .............. •---.-- --•......_.....- . ......... ...... ....................... ......... <br /> ii <br /> ...... <br /> Final fns ecti <br /> .. <br /> ... . .............•.......................... <br /> 6n by: ..............Date _.. ..—...z .--. <br /> EH 13 2h !l-bti Rev. 5m SAN JOAO N LOCAL HEALTH DISTRICT 8/7h 3M <br />