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FOR OFFICE USE: FOR OFFICE USE: ppLICATION FOR SANITATION PERMIT 77_ --5- F------- --------------------- --------------- Permit No.......... ---- - [Complete in Triplicate) ----------------------------- - "''J ----- Date Issued-.rf -e - ---- ------------ ------ ----- This permit Expires t 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. is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: . .........CENSUS TRACT.------------- --- --- --- ---- JOB ADDRESS/LOCATION.- --- - ------ .--ti ------ ---- wner's Name---- - "� '�-_ __ !( � "'�" - ------ ------------ - - Phone p / �- -------Zi �ddress--------------------- -f G-_- - �L .,{� C'tY `�`� p r� Contractor's Name --- ' - C � .� ---l------------License #.. Phone will serve: Residence E] Apartment House❑ Commerc fistallationial 2 Trailer Court ❑ Motel ❑- - Other----------=---------------=----------------- (NNI umber of living units:----------------Number of bedrooms_._----____Garbage Grinder..___.-__.-Lot Size --------------------------- -------------.._--.-.-------- 1 # {Vater Supply: Public System and name - --------------�--�- -- -------�-----�- ----------------�------- �------------------�---- ------------------ -_Private Character of sail.to a depth of 3 feet- Sand ❑ :Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan I Adobe❑ Fill Materia-_-___-_._If es type------------------------------ a yes,fi'p '-1�Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on revexse side. NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) F?ACKAGE TREATMENT [ ] . SEPTIC TANK [ ] Size------------------------- ------Liquid Depth.------------.------------- Capacity---------------------Type- -- --------- ---Material---------:----------------No. Compartments-------------------------------- Distance to nearest: Well- ------------------------------------------Fou:ndation--------------------------Prop. Line-------------------------- [EACHING LINE L] No, of Lines---------------------- -----Length of-each line------------------_--.--------Total Length -.----------------------------.-------- 'D' Box------------Type Filter.Materiai--------------------Depth Filter Material-------------------------------------------------------------- } Distance to nearest: Well---------------- ------ - Foundation ...-----------------------.Property Line------------------------- ------- SEEPAGE PIT ------ Diameter--------- m - --------------- Rock Filled Yes [J No Water Table- ----- Rock Size------------------------------------------------- Distance onearest: Well_------ --- ---Y - - _ = --------------------------Prop. Line---------------------------- y REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- ----- - ------------Date-- -----------------------------) peptic Tank {Specify Requirements) - ---- Dis.posal Field(Specify Requirements) Gym r _ �� J l — — ------------------------------------------------- 4 -------------------- -- ---- --- ------------ --- (Draw existing and required addition on reverse side) F 1hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t?rdinances, 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 perfoirnarice 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 Title.... (If other than owner) � ` F R DEPARTMENT USE ONLY [APPLICATION ACCEPTED BY--- - - ------------- -------------- -------------------------- ---------DATE.-9.--.r19- DIVISIONOF LAND NUMBER....------------ ------------------------------------------------------------- ----------------------------DATE.._-------------------- =----- --- ADDITIONALCOMMENTS------ ----------- --------------------------------- ----------------------------- -------- -------------------- - - - -------------- --------- ------------ i i-Al ------------- --------------------------- ------------------------------------------------------------ ---- --------------Z3 FFinal Inspection by ------------------------------------------------Date. `----------------- ----------- -- -il ai 13 24 SA JIN LOCAL HEALTH DISTRICT Fes zien xev. �I76 ann i