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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permx,71907) - F - I .- it No.- - - ----- -------- p -------------------------------------------------- ------ --------------------------- ------------� (Complete in Triplicate)I I Date Issued__ _-.=-P'-77 d ------- _ ,This Permit Expires 1 Year.From Date Issued„ •-------------------- Application is hereby made to he San Joaquin Local Health'Distrid,for apermit to construct and install the work herein describ d. This application is made in co pliance with County Ordinance No. 549 and existing Rules and Regulations:, � y CENSUS TRACT JOB ADDRESS/LOCATI N-. ' S,T .fes- --- ------------- --- -------------- -4 - IQj Phone Owner's Name------ - -�/ --- ------- -------- ------- --- ---. ------ .---- -------. ------------- ---- ` : � g Y �} _�o� "----J '� S-----:--- _...-- 'City G --------------- Zip 'f''2p'�. Address ----'- r.a p� Contractor's Name-- �_s� , `1'"`"_. t License # � 3 Phone--- Contractor's - Motel Other _=-:-____.,_:.s -=mercial L] Trailer Court ❑ ' i ❑ Installation w111J serve: � � Residence` A artment House. : Commercial -- ! � f <, p ❑ Number of living units:-. _ -.........Nu bei of.bedrooms_- -_-Garbage Grinder----_----..Lot,Size=- p-- -------------- - D -� Water Supply: Public System and name --- � "" "� �" 3 '--------------------- - ---- - Private Character of sail to a depth of 3 feet ! Sand ❑ Silt Clay ❑ ' Peat❑---• Sandy Loam's Clay Loarn Hard an -_ } r 'P ❑ Adobe Fill Material If yes, type j. (Plot plan, showing size 'of I'ot location of system.in relation to wells,buildings,.etc. must be,placed on reverse side.) ` :; ! i NEW INSTALLATION: '(Nd"septic tank or seepage pit permitted icpublic sey(er is available within 200 fee#,f R� PACKAGE TREATMENT [ ] SEPTIC TANK' ;:,-1 Size--; _pC_ / - --__='--`------= Liquid Depth. "--7" --- II:, = T e� - , w -- - -� ; . ------- ----=-- Capdcity - �� yp ----------- ---Material- No. Corrtpartments--------------- s t ;.Dista ce to nearest: Well-----------------------------=--= ------Foundation_- "".Prop. Line- ---------------; Total Len th.' 11 0----- ---_ LEACHING LINE No. of Lines_.;-z---- ------------ Length of each line.---- " . .-. a th Filter -- i 1 ��: .. to !'D' B')XIJ--- ---Type Filter Material Ma tial � , ---------------------------------- Dist nceto nearest Well_l --Foundation-: �------ Property Line---------------------------------- SEEPAGE PIT Depth -__Diameter.k _:---.Number-__ Rock Fi ed Yes No f --- ------------ D� p. , t t Water Table�Depth.---E�--------- -�---- ----- ------------ Rock Size=- -�-�Z- �-� Dist a�nce'to nearest:Well-=------ ----------------- --------------Totindbition-----=-----------------._.Prop. Line-------- ----------- ... = Date -------------). REPAIR/ADI?ITION (Prev-Sanitation_Permit#-----------==------ ------=----- ------------------------- t. : Septic Tank (Specify Requirements)----- ---- ---------- --------------------------------------------- -------- -,------ ---- :_- ------------ ------------------ . w.,. - Field (Specify Requirements) -::: -- - -------------------------------------------- ---------------------------------------- --- - i--------------- ---------- ---------------------------------- Disposal Ili -- - . --- ---- - , -. - _ --. - --- . -- --------------------------------.----- ------ ----- ---------------------------- ----=------=----------- ---- -- (Draw existing and required addition on reverse side) I hereb certifY that. have �'repared this app lica Y tion and that the work will be done in accordance with San Joaquin County Ordinances, State Laws; arlpd Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the or�ance of the work for which this permit is.issued, I shall' not employ any person in such manner as to become subject t orkm an's Co nsalion I ws of California." i Signed ? x ► ------------- B ----- ---------------- ------- k (If other than owner) FOR DEPARTMENT USE ONLY i " ----- --- - APPLICATIQN ACCT=PTED BYE ----: DATE .1� -- ---------- ---X ----- DNISION OF LAND NUMBER _ -,: - DATE---------------=--- ------------ ADDITIONAL COMMENTS-..� ----------- ------------------ ------------------------------ ------ -------------------------- --- ------. ------------ - ------- ._. - - - --------------- ------- Final Inspection b � - --Date _. - EH 13 24 SAN JOAQUID4 LOCAL HEALTH DISTRICT F&S 21166 77 REV. 7/76 3M