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FOR OFFICE USE: FOR OFFICE USE: .'.r Permit No._77_� APPLICATION POR SANITATION PERMIT 3�- 7 ---------------------------- w` --- --- ,,,� � ----------- -- (Complete in Triplicate) ------- -------- ----- jsti Date Issued..Yo'7 This Permit Expires 1 Year From Date Issued 4. 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 Irll0...�/� ;------C�/-"7/-'---------------- ,.----- ------.CENSUS TRACT ��_-- ----------------- �.,.,� , ~ Owner's Name..'}'! %ll1QfZ/ ------ -- Phone .. `.ff - — Address---- �� c3.c// ----------=------- ------ --------------- " 'City - ---- Zip -- --------------- License #. Phone.._ - Ary s Contractors Name< �. �?�/7� - ----- - ------ ----------- ----.----------- -- ' ] Installation will serve: q Residence - Apartment House'❑ Commercial E] Trailer Court ❑ { .. Motel ❑ Other.--------- -- --------=-------- S Number of living units:___---------Number of bedrooms__3._..___Garbage Grind Lot Size------- 5 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 0 Fill Mdierial____.......If yes, type....................:......'---- Mot pFa-n, 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 pe rmitted"if publ ig sews' is available within 200 feet,] • �, `` �; ` ACKAGE TREATMENT`( ] SEPTIC TANK I �,�r.1 Size 'a� /� ' =-Liquid-Depth -------------------a �Ci3- -i.ar _ ., . Capacity --=-----=-----=---Type --- Material i - �""No.�C mo partments '---- � 1 t ,F Civ !z` Distance to nearest:-We]I ------------------------------------Foundation----------`- _' � Prop Line---------- ----------------0 - '-_ Len th.of,each line.. - --- ., Total.Length. --� 4� LEACHING LINE, [ ] No. of Lines------- _�_ _ � � D Box- -.-- ;--Type Filter Material--� - - DeptK-Filter Material----------------------------------- -------------------------- o C * ^ Distance to nearest: Well----------- ------------Foundation----------------------------.Property Line.--------------- ------------------.0 SEEPAGE PIT :[ ] Depth________________Diameter_..�; _ ----- Rock Filled Yes E] No E] 3 Number - �} Water Table Depth--------- ------- -------- -----==---------------------Rock Size-- ------------------- --------------- tf Distance to nearest: Well---------------------; ----------------Foundation-- .----- ------ ------.Prop. Line-----------------.---------� ,,REPAIR/ADDITION (Prev:'-Sanitation P�er�mit#.- :-- - -------=----------=`-------,Date-_______...- -- -------------------------) Septic Tank.(Specify _F--------- ------------------ ------ ------------ , Disposal Field (Specify Requirements] ~' -------- ------------------------------------------------- -----------------------------------------r- ------------------------- -------- k �•, d -------------------- Y 4 ------------------------------------------------------------------------------------------------------"----"-........-----........-------- _--___.....-.-____ :- ___......._____.... II ---------------------....-------.....-----...--------------------------------------- ---------..-.------...-._----......----....------..-._------------------- (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: "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 subject to Workman's Compensation laws of California." - Signed-------- -------------------- - ---------- -------------------------- -------------------------- ---. Owner By-------------------- -------=-------------------------------------------------------------=------------ Title (If other than owner) R DEPARTMENT USE ONLY -`=� =-------- ---------- ---..DATE. - `% ----------------- APPLICATION ACCEPTED BY:_. _..�__ _- ----- DIVISIONOF LAND NUMBER.-------------- -------------- -----------.DATE-------- . i------------ ------------------ ADDITIONALCOMMENTS----------------- --------------------------------------------------. -------------- ----------------------------- ---------- ---------------------------- -------------------- -------- tl - - _ -b - - - - -- - - --- - -- --- -Date2--------------=--------- Final Inspection - . - - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M 1 -