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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------- r Permit No-..-77--.7/4 (Complete in Triplicate) J /—77 ---- - - Date Issued_-� -_...-...._- --------------_-------_---------------------._.__...._. 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TION..l� � '-.`� =_ . - .- !`�` r - --( ,y - -r�c.-.CENSUS TRACT --------------- t.7 -- - - Owner's Name 'UZ - ---------- Phone AddressYD , ::;-- ------ - 1 City Zip e Contractor's Name_ -�� c License #. ------------- Phone GV Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------- ---- - - -------- - - \� Number.of living.units:..i.�-._.------Number of bedrooms._._-.Garbage Grinder----- ------Lot Size__-______...- ---------------------:_- Water Supply: Public System and name-------------------------------------------.-- ------------------------:--------------- --------- = _ Private. Character of soil to a depth of 3 feet:/ Sand 0 Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ ClaysLoom E:] Hardpan M Adobe ❑ Fill Material-------------If yes, type------ ------.__.._______ . (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must beIpldced on reverse side.) NEW INSTALLATION: .:(No septic tank or seepage pit permitted if public sewer is.aJailable within 200 feet,} " PACKAGE TREATMENT [ ) SEPTIC TANK ['J ° Size 4X _fT z- - Liquid Depth---------------------- _.- s Capacity------------- --------TYPe-------=- Materia.-_.f -------[No. Compartments---------: Distance to.nearest: Well.. _ -- '._._ Prop. Line ----- --- tl LEACHING LINE [ No. of Lines-'v --'-- ,_.=._-._.Length o each line..-__ G. _ .. (1 - � - -- - - Total Leng#h..--��---�--- - � ,.fes a .� �- --` ---� , a D' Box....r-- •_.T. a Fitter Material'---_- -- '-----De .h Filter/Material_____1I-__..._..____-_____-------------------------- YPP` Distance to neare t:Well- -524r, -___Foundation------ /7� ---------.Property Line-----s_- SEEPAGE PIT [ �,rtDepth____.__ r_ iameter.... J.._.....Number.________ ,._._._.. -_ Rock Filled Yes [ No[5 -- a` Water Table,Depth---------------9- ---- --- --------.---.Rock Size---- � Distance to nearest: Well---- _' ----------------'Foundation.._--- Q__ p. } 1 - ------:..Pro Line �� REPAIR/ADDITION(Prev)Sanitation Permit#----------------------------- ---------------------Date------------------------------------------ --- -SeptSepti c ic Tank (SpecifyReq uirements)----------- --------------------------------- ----------------------------- ------------------------------- --- -------------------- Disposal ------------------Disposal Field (Specify Requirements):- -------- ---- ---- ------------------------- ---------- -------------------------- --- ------------------------------� = :---t-------------------- ------------------------------------------------ --------------------- ------------------------------------------------------ ------------ ------------------------------------------ -- --------------------------- ------------------- ------ (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 l' Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed ae.anJs___J 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------------------ ----i----- --- = - - - Owner _ BY =-------------------- r 'yr t�� Z ----- -------: -- --Title-- -� �e v------------- --- ------- t (!f of er than owner)' . ~ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------ = - DATE. DIVISIONOF LAND NUMBER -------------------------- ----------------------------------------------- --------- ------------------DATE-------- -----=----- ---------------------- ADDITIONALCOMMENTS-------- --- -------------------------=----------------- ---------------------------- --------------------------------- ----------------------------- ---------------- -----=--------------------------- ------------------------ -------------------------------------------- ------------------------ =---------------- ----- ------------------------ ------------------------------------------ ------- ----------- Fina! Inspection b - _ - ._... Date-----/9 �-- . PY "d - - ------------------- EH 13 24 ` SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M