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Y FOR OFFICEUSE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - -- - `, ----------- --- Permit Nn - -.'� 3 ti (Corpplete, io Triplicate) 7 - .............. ..... 7 �^ Date Issued--- --___/ -7 ._-----�---- -------------------------- This Permit Expires 1 Year From Date Issued 77 Application is hereby made to the Son Joaquin Loral Health District 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 ADDRESSILO TION.- 102_Y•21.--•- _ - - .- 1 / ---.-----------..--------------CENSUS TRACT.-. -.-.�� ... Owner's Name �jG �s -..., �1�. p� Phone--. -7--- Address ---- ------City-- . C��O-f}.----------- ----_Zip - Contractor's Name-- ------ ...± j�G . ....-....! :...... .License #. ,r �i_- --- -Phone--- � Installation will serve: Residence❑ Apartment House (,ommerciahf�-`Troiler Court ❑ Motel ❑ Other- ....Gl ... ..-------------- Number of living units: ....Number of bedrooms. .... _.---Garbage Grinder............Lot Size-------------------------------------------.-__•------------ Water Supply: Public System and name-.--..-------- ----------------------------------------------------------... ---•------ -•-•------•-=----- -•---- ........Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam,p-- 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 seep ge pit permitted if public sewerisavail Ole within 200 feet,} PACKAGE TREATMENT [ ) SEPTIC TANK [7 Size------- 9y--(_- --' ---Liquid Depth--7o7__+'------_ Capacityle GQ.r .-Type._. •-------Material -aw-------------No. Compartments ......�---------- --------- Distance to nearest: ----------------------Foundation_]-4/--____-------Prop. Line-- Q____--.-_... rj 1 I LEACHING LINE [�No. of Lines..... ...!._•----------Length of each- line-- --------------______-------Total Length ----___ -------.-----------...... 'D' Box.- o-Type Filter Material._/*_//'--Depth Filter Material-------�___-.________________-.____________-_--____-----• Distance to nearest: Weil__f_3 f-.--.....-.-Foundation...- .s ..�........Property Line.... ��_________________ SEEPAGE PIT p �`5'.f. .-Diameter . �� -----_ Rock Filled Yes��No❑�De th �---- - -Num6et--------�_�------- Water Table Depth.............. �� .--• • -----------------Rock Size---/.."`7 . ...... a......._....... Distance to nearest: Well... 'S --------Foundation-__w7 ......... Prop. Line...-ti,'��.r__-__:: REPAIR/ADDITION (Prev. Sanitation Permit#----------- ------------------------------------_Date......._.__..._.-_....._.__._.._..-._..-_...-.) SepticTank (Specify Requirements)--- ------------------------------------------____...............................----•.......-------------------•---- ....... ....... DisposalField (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. Horne 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 subject to Worlkman's Compensation laws of California." Signed---- ----- --- ----- ----- -----•- — -----------------------------Owner - By........... Title I (If other than owner)- FOR DEPARTMENT U ONLY ABU PPLICATION ACCEPTED BY.-• ----- 67� ------------------------------------DATE --- 7" DIVISION DF LAND NUMBER ...................... -- - -----••--•-•---------•--------------DATE......_.--•----••-•--•----- ................... ADDITIONAL COMMENTS------------------------------------------•--- .. -------------•----•-•••- •....................___- - -•----------------• . - ------- C - -----•------ .....-. ------- Final Inspection by-------- ----------------- ------------ - •------- ...........................4__....Date.......... ./.-. .... .. . ' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FdS 21677 REV.7176 3M