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7 FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit N.___7__7-__3_3F ------------------------- _�=.�7_______ ---�---� - ------------ -�---- --�---•---------- _ -•----------------------- -- -------------------------.-- This Permit Expires 1 Year From Date Issued Date Issued- z �'It'd-al . � t`�,._' �"`• Application is hereby made to the San Joaquin cHealth DistrictP 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/LOCATI _f _'� --- A ON.. � GCSE - �--� ----- -------- ---.CENSUS TRACT------------------ ----- ------ -- - ----------- Owner's ----Owner's Name. 1 '� .. -. - _-,.-E - one E _ +_ , _RcAddress -CitYZip_____ ______ ____ _________-.. . Contractor's Name---- 4-S,kKS _ . Y_W2C--------------License #4sF' �K�---. Phone._.Z44 -yd/2 Installation-will serve: Residence; Apartment House.❑ Commercial E] Trailer Court E] ;y 'r/, .Motel ❑ - Other---=------ :_ '= # Number of living units:------ �'N' umber of bedrooms---Garbage Grinder-------------Lot..Size--. - _----7 ___-.-- _.____ Water Supply: Public System and name""' '�..-------- ------t-------------------- -.---- ------------ Private Character of soil to a depth of 3 feet: , Sand ❑ --Silt❑ 'Clay ❑ ' Peat ❑ Sandy Loan :4 Clay Loom ❑ Hard an Adobe ' r p ❑ ❑ Fill Material- If,yes, tYPe = `= (Plot plan, showing size of lot, location of system in relation to wells, buildings;:etc. riust be placed on reverse side.) NEW INSTALLATION: (No septic fank 'or seepage it permitted if publk sewer&i is within 200 feet,) p PACKAGE TREATMENT k f l � 'SEPTIC TANK �- "� ' "Size_ _ � d ---_ �--��`.----��----+�--,---- ----Liquid Depth_��-------- ,,e - - Capacity_�C�-An _3_ � Typerte- `---Material__ '_ -- -__No. Compartments--"-Z. iEo R t¢ ✓ d Compartments-=_Z.------- -©----©------_-----_____'_- _ Distance to ne � / Foundation '�_ -- --- ----------Prop. Lin ------------ LEACHING LINE - , No. of Lines- _4 h'lin_e.�' ..=-______________Total Length.___._. .. ; a,._.- of-par tt r D' Box.__._1.__'_.Type Filter Material -.Depth Filter Material ------ _ ____ ____ ---------------- i f - Property j �0--- Distance to nearest: Well___ _. `li--- L _ _ / p ty Line r SEEPAGE PIT Depth_.I-Z_,____Diameter.`�^_x_�._ _ N.Umber---_-------��---- -------- Rock Filled YesK No ❑ Water Table'Depth---------I-Q ------ Rock Size_ f- - ---------------------- Distance.to nearest: Well.-__��_Q___..:___��___-._._ Foundatian.___�l�_----------Prop. Line___�c'Z2 __ __ REPAIR/ADDITION (Prey?Scxnitation Permit# r -- " ----------------;;--- ---._ 15ate--:----=----=-------------- ----------------- ------------ ----------- -- 1 Septic Tank(Specify Requirements).--- '----------------- �-- ----------------=----------- -i}= _------ ----------------- I If - - - - - � - `- -----------',__ � +--'�- -----------------------� -------------- Disposal Field (Specify Requirements):---------------- ---------- ' ;--------- --- r . 4 ' ` = f ----------=-------'= ` --- =------ __ (Draw existing and reggwed addition°on reverse side] _ ? -'r I hereby certify-that I have prepared this application and that the work will be done in- accordance with San Joaquin County a Ordinances, State Laws, and Rules and Regulations, of the San Joaquin+.Local Health District. Home owner or licensed agents signature certifies the following: i "I certi 'that in the a` fy performance of the work for. which this�ernlit is is�[`iexlr;= I shall not employ any person in such manner as tobecome subject p Workman's C m ensati laws of C lifornia.- djs�� I 1 n A ., SI g ned. R T A ----- - - . _ { �rrer By-.------ ------------------------ ---------------------- ----------- - - ---- f +�iJ -Title' (If other fhan"owner) N, FOR DEPARTMENTUSE-ONLY - APPLICATION ACCEPTED BY:__------ -- - ---------- ------=---------------------=------ -------.---------------=----DATE -_ *._ -� DIVISION OF LAND NUMBER._._________ . -- ------ ------- ---- - - ---------- - --.DATE.---------- --- -- --- -------:----- ADDITIONAL COMMENTS----------------------------------------- � - J _______-------_------------------_---_-------- ------------------------------__---------------------------------_----------------------------------------------- i _ -- ------------------------------------------- _____,------------------------------------------ ----- _2____-- --- - - - _ _---__-_ -ZI'12 -7 Final Inspection by:. - = ------ ----=---=---------=------=--------------= ---------------Date----- ------------- £H 13 2d SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M {