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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.--77-_x--- G�3 77 ------- Date Issued.l 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 installhe work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulat �sl JOB ADDRESS/LOCATION-- -- �I6 2-------LU- LA_NCF------------b.-�,---[&$_..--*[ ---CENSUS Zj(� Owner's Name------------130eT----- 11-ZN-- -- -----------.Phone-------- --- . v- ------- -- -- Address--------- --- - -_-_----- -----------------------------------.---------------------- .....--------- -- City - ----------------------------------ZiP------------------------------ Contractor's Name----------------owwoQ--------------.-------- ------.--------License #-------- --------.--- ..__-Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court QJ Motel ❑ Other---------------------------------------------- Number of living units:-------I_-------Number of bedrooms------------Garbage Grinder------------Lot Size--------- __f. ._._._._ ._ Water Supply: Public System and name-- ----- f------------ -------=--------------------- ---- --- -- ------Private [�-- Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ 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 seepage pit permitted if public sewer is available within 200 feet,) p PACKAGE TREATMENT [SEPTICS fT�A�NK [ j Size______________________________.---------------------------Liquid Depth -----_____._____--- ----- Capacity....li'-n--------Type.--6-CR>�-------Material-- sr ------No. Compartments----------z---------- N _ ____ Distance to nearest: Well-----rjenl __�dCJ_____________________________Foundation. _aAProp. Line._.._ _._______.___. -_ --._..__________. LEACHING LINE [ No. of Lines-------------------------- - Length of each ling_.-------------------- -- ---Total Length ...--------------- --------- 'D' Box------------Type Filter Material------------------- Depth Filter Material..-------------------------------------------------- FL�ve Distance to neare t: Well____________________ _____ _Foundation.___._z-U.._------------Property Line-------fi -- - - -- 1 )OY-30 %A� V, SE€ - [ ] Depth------ --------rZme#er--------------------Nonftber_..----------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth-----------------------------------------------------_Rock Size --------------------------------- Distance to nearest: Well-------------------------------------------Foundation-------------------------.Prop. Line-------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date---.------------.-----------------------------[ Septic Tank (Specify Requirements)______________________________________ Disposal Field (Specify Requirements)---------------------- --------- - -- ------------------------------- ------------------------------------------------------------- --- ------- -------------------------------------- (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 sub'ect t o an's ompensation laws of Californi " r Signed Owner By--- ----------------------------- ---------- -------------Title----------- -------------- - - ---------------------------------------- (if other than owner) FOR DEPA ENT LJ E OtALY APPLICATION ACCEPTED BY---------------------------------- - ------- --------DATE _.__ --�>- .-----------. - - - - -- -- DIVISION OF LAND NUMBER ------------------------------------ ---- ---- - -- ---....-------------------DATE.------------------------------- --------------- ADDITIONAL COMMENTS ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------- --------------- ------------------------------------------------------------ Final Inspection by - - ---- - -- --------- Date /f " T77 EH 13 24 SAN JOAQUIN LOCAL HEALTH RIOT Fes 21677 REV. 7176 3M