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FOR OFFICE USE: - - FOR OFFICE USE: C APPLICATION FOR SANITATION, PERMIT PAI........ .... ........ Permit No.. (Complete in Triplicate) � K. ......... ----------- 1A_............ ........... f Date Issued.11.. 7�Z 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,install the work herein described. This application is made in compliance with County Ordinance No. 5 9 and existing Rules and Regulations. JOB ADDRESS/LOCATION -......Vri 1�-_ . . ..... -CENSUS TRACT Owner's Name......Cl� 0./✓� (�1.-- � - _ .... Phone . ..... Address. . !� �� ti'... ---- - ----------------- --------- City ..._... ------ Zip ._. Contractor's Name---..... ---- ---•----------- - ------------License #.o�G J. Z. .....Phone. �". /�1 ....... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer.Court ❑ Motel ❑ Other------------------ ---------------•---------- Number of living units:...... ----..--Number of bedrooms.... ......Garbage Grinder_../-------Lot Size....-.l.,.�_P.-- 1 :.--• - ; Water Supply: Public System and name--- - ------ - -- -------------•--• -------- .... ---- -----.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.[ 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,[ � 44 PACKAGE TREATMENT [ ] SEPTIC TANK 1 Size----------------------------------------- ------ -- ----Liquid Depth..,.-----..--- Capacity� yp �rCQS�...Material.. - --.--.----No, Compartments...... ._,'--------------------• Of Distance to nearest: WeIL._...� �..............._......-------Foundation...__,�Q_ ._._......_.Prop. Line..... LEACHING LINE [ ) No. of Lines...-------°V----------------Lengt of each lin ------_----- Total Length _....� .�------------.-- ----- - _ tt // . 'D' Box............Type Filter Material . _ ..1 pth Filter Material------ - i-_ - --------------- .............. Distance,to nearest: Well----- � ......--.Foundation._..._ -------------Property Line........ -- -------- - t --- Yes 1T [ ] Depthta _Ip...Diameter..- ..N �l� � ;.. umber -------- - ---------------- pt .-.Prop. Rock Fill No fWater Table Depth . . Rock Size.-.4 -- f - - - --------- / ,Distance to nearest: Well.--- ;i -------------------Foundation_ Line..;�.�_:�.'�: -..... REPAIR/ADDITION (Prev. Sanitation Permit#------------- Date------------......._-...----------------------] Septic Tank (Specify Requirements[......... ........ . ----------------------------------- .......... Disposal Field (Specify Requirements).....____t...:..._.... ....................... . ............................ ---------------------------------------.---------------- - ---.....--•--------. ................----- ------ .... ----------- ------------------------ ----------------------_- ------ ----------- - ---------------- ---- ------------ {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-Son 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 subject to Workman's Compensation laws of California." f .......� .--_._..-_ Owner Signed ----------- ---- SY-• ---- -----.Title----- --- ------ - (If other than ,owner) FOR EPARTME ONLY // APPLICATION ACCEPTED BY----... / ^u'"-'--- --- - .. I............ ............ ....DATE.------�f -7 ... - --_-- DIVISION OF LAND NUMBER----------- -------- - ------._ ------------------DAT ADDITIONAL COMMENTS..................... _....---- ......... -- ---•••--- --- ---•----- ---- / - - / / /� Z� Final Inspection b !l f! . _ Date._.... _ Y ---------- EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT Fad 4 77 R 7/76 3M