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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ (Complete in Triplicate) Permit No.___ ---5�---/ --------------------------------------------------------- ------- This Permit Expires 1 Year From Date Issuer! Date Issued__-/cF'-77 Application is hereby made to the San Joaquin Loca! Health District for a,permit to`•constru"ct and�instdll the work herein described. I This application is made in compliance with County Ord' once-No.1549 iand�ezistin'g Rules and Regulations: r JOB ADDRESS/LOCATION_,$,, - . --7174-- ------ - ---- -- ------------------------CENSUS TRACT-------------------- --- Owner's Na Owner shame - ------- ----- P a hone Address----------- �1 TT ] --Zi Contractor's Name._. License #___- Phone.- p r Installation will serve: I Residence Apartment House.0 -Commercial ❑ Trailer Court ❑ }� i lofel ❑ Other Number of living units:__;- l ._Number of bedrooms;____._ ____Garba e_G�inder_ __ LotSize__�k2A, -- � I _ ------- ----------- Water Supply: Public System and.Home = Private ❑ i Character of soil to a depth of 3 feet: Sand (] Silt E] Cla ❑ 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 se age pit_lpermitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [] SEPTIC TANK [ ] ( Size___'_ ..__ A_lp------------ -----------Liquid Depth.---1 ----- ----- -X- t capacity-J;? r ��` TiYPe " - "----------Material-- /r_i,...� No.<Com artrl�e .- _nts__ --------------------= Distance to.nearest: Well-:-'- ---------------------=--------------Foundation-------------------- ' .Prop. Line LEACHING LINE "" I,] No. of Lines '_____.Length of each line.__ _ __.Total Length___, ,,._._ _ 1 ._ I� Distance/nearest: il If___ Tial f __" Depth Filter Material--------/ �___.-_----_.____:____.__._. ,D' Box__--_ _.___Type Filter Mater i E -------.Property Line-------' ----------- ---V i ------- ----- oundation ❑�.' . �[ ] Depth --- �--- - T SEEPAGE PIT Diamer- _______Number___,___ Rock Filled Yes No Water Table Depth- -�-------- ---------------------------------.Rock Size $ ------- 4 v iell_.. a Foundation _4 —Prop_ Line------------- ----- REPAIR/ADDITION P ° i .. istance to nearest:W 1 �....-.._,__:_..� R rev. Santation Permit#___ ----------------------1--,Date ( I -----'--=------:--`p-' -- - ---------------------- - - T -i Septic Tank (Specify Requirerrients)_____.__ -- --- ------------ --------- ------- -------------- s ----------------------------- Disposal Field (Specify Requirements)---------------`--- ---------------- ---- - r�-„s -'� - ---F---------------- --- i ------ -------------- ---------------------- -------------------------� (brow existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work-will-be d'o-ne in—accordance with San-Joaquin, County t Ordinances, State Laws, and Riles and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I cern that in the l j '� ' _ '"` certify performance of the work for which-this�perritit�is�issued,"f"shall'nof�•employ any pe"rsori in.such manner as to become subject to Workr,an's Compensation' laws of California." Signed-- [ O - -- -- --- �- -------------- -- --------=------- caner By--------------- - - ----- ------- - --------Title-------------------------------------- -------- If. --If. ther than own 4 / FOR D ARTMENT USE ONLY APPLICATION ACCEPTED BY-1- . -------------------------------------------------------- ---------------DATE, /� i yr ' ---- y DIVISION OF LAND NUMBER.- '- -- ----- --- -------------------- DATE ADDITIONAL COMMENTS - A-- --- ----- : --------------------------------- ------------------------- ----M- �-T- _ �rt � .�_.--- _ - ---- ---- - --- ------------------------------- ----------------------- -------------- ------- ---- - --- ------------ ------------- ------------- - ------------------ Final Inspection b : --- -------------- ;6..; P Y .c Date----------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV, 7/76 3M l