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OF of CI '�' - 1stskaF y c s FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Corrrpete in Triplicate) Permit No._7 6-.-._-.____ Date Issued._ 7_/7 78' --------------------- ----------------------------------- This Permit Eae'pires 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/LOCATION-^--.�-------1--- � 4►--- -- --------- -------------------CENSUS TRACT----------- --- ------- --- Owner's Name CvK sal. ------ -Cy_p ------------ -- -- -----------------------Phone_J�S�a. T 7�: Address-- io � -/. -----------------------------City T Zip Z3 ------------ Contractor's Name --------------------- -License #.X 1Y ,3 -Phone__��`��47----- ". Installation will serve: a ResidenceApartment House.❑ Commercial F1Trailer Court ❑ fi.....a.. Motel ❑ Other.--- ---------------------------------------- t Number of living units:------ -------Number of.bedrooms_._3_____Garbage Grinder------------Lot Size ----------------------------- { 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-------------------------------- (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 w thin.2.00 feet,) ir PACKAGE TREATMENT i [ SEPTIC TANK . Q Size- --_- ---------------------------------Liquid Depth--.-,! . t------- citY1 Type tments< aWCa ._-Material---&---- ----No. Compar ------------� Dist __________ _ __ _ _j--------- Foundat!on------ _._Prop. Lin --------------=---E LEACHING LINE No. Lines.------- —.-----.-- _-.Len Length of each line ___ - _--._ .Total Length � +_ , i D" Box.._.. _-Type F`68r'Matereal--- _ p� - f � --- �.De Depth Filter Material --'•1�-�--r----------=---- -�------------------:._.:---- # Distance t nearest: Well----- -- ---'__.-_ _.Fou ndation------_�_Q_-''E'______: .Property Line__._---- - SEEPAGE PIT Depth.. .51 .YDiarraeter '�,J__.____Number_____=.__ _______________ r� Rock filled Yes No ❑ Water Table Depth--------------- -----------------------------------------:Rock Size, y {-- a' Distance.to nearest. Well__�___...1_ -----------------------_Foundation----.__tQ;__�___-.--.Prop. Line_.s-------------------- REPAIR/ADDITION _--____ -_ --.-REPAIR/ADDITION (Prev. Sanitation Permit#--------------=-------------------- .--.-----.Date_--.•. ------.- ---------------------------_--" i � Septic Tank (Specify:Requirements)----------------- -- ----------- --------------------------- ----- { -------- A- 4 i --------:--- --------------- Disposal Field (Specify Requirements)-------- ----------- ------------------------------- '----------; ---- ---------- &----------=-------- ------- i ------------------------------------------------------------'--._ ---------------------------------------------------_________•_-__ y . e (Draw existing and required addition on reverse side) a I hereby.certify that I have prepared this application and that the work will lbe done in ac cordance with San lJoaquin County Ordinances, State Laws, and Rules and Regulations of L the San Joaquin Local Health District, Home owner or licensed agents"",i signature certifies the following: y '� "I cern that in the certify performance of the work for which this permit is issued,1 shall not employ any person in such manner as to become subject .to Workman's .Compensation laws of California." Signed--------- ----------------- :Owner [ h BY = ; - =Title ----- -----. ~ -y (I ther than owner) FOR DEPART T US ONLY 'Y � F/ APPLICATION ACCEPTED BY-.__-, /tom__._ n`'� t- DATE = f DIVISION OF LAND NUMBER: 2 =--- - - - ------------------------------- -=-- -DATE--- -------- -- ----:-'---- ----- ---------- t ADDITIONAL COMMQNTS.............. VC- --------------- a �� ------------- -------- --------- { ----------- ---- ------------------------------- ------------ m - --------------------------------------- -- --- - ----------------------------------------- ----------------------------------- - _ g ----- - -------- Final Inspection by:- -- _.._---------- ----Date--- Iy7 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT JJJJ F&S 21677 REV. 7/76 3M 1