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FOR OFFICE USE. APPLICATION ICOR SANITATION PERMIT (Complete In Triplicate) Permit No. ,F-40.. ............-.............:.:............__I._.......... - This Permit Expires 7 Year From Date Issued Date IssuBd-5.":4,_ 7 7 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. 549 and existing Rules and Regulationsi" JOB ADDRESS/LOCATION .......... •..:...._. ..... ......... �' ......CENSUS TRACT .......................... Owner's Name ...................... lrsfrxe. cr::7'` .1.:.....e r..... .. ........... . ............Phone . .�s:'1. ............ s Address ............1-`T--rP._. p e /..... ...... City .. c'k--y� 7 .... . Contractor's Name :�-_ - -..-. k,_Q�pgsd� ...................:.•-•---.License # ...._.... -------------- Phone ------- .................. I Installation will serve: Residence❑Apartment House❑ Commercial❑Troller Court Motel ❑Other.................... Number of living units:............. Number of bedrooms ............Garbage Grinder ..._ ....... Lot Size ............................................. Water Supply: Public System and name .........................................................------------------- - -------------_---.----------Private 0 Character of soil to a depth of 3 feet. Sand b Silt❑ Ctay ❑ Peat❑ Sandy Loam f] Clay Loam ❑ Hardpan❑ Adalse❑ FIII Material ------...... if yes,type ............... ............ (Piot 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,) PACKAGE TREATMENT SEPTIC TANK f. { ] <X Size.•---------------- _-.-----_...-•--- Liquid Depth .---•-•--.....------....... . Capacity •--------- -•----- Type • .... Material....................... No. .Compartments ---------------------- g. Distance to nearest: Well ..........................••--------Foundation_ :. -:............ Prop. Line ------!_............. LEACHING LINE ( No. of Lines ........./__.... Length of each line....:...- o___-.(� .• Total Length ....3,P................. N 'D' Box .1to_1?n4ea -_. Type Filter Material ..:..................Depth Filter Material ............................ o r Distance res#: Well ..............4.------.f Foundation .._._................. . ,Property Line. ............. .__._...... SEEPAGE IT ` ( Y Depth ... Diameter Diameter }. Number ..................... .•-•--.. Rock Filled Yea [ No. Water Table-Depth Rock Size -----..:......... 49 7b ••---- ----------•- / i Distance to nearest: Well ... . :Foundation ................... prop. Line --•-•-•....... . p REPAIR/ADDITION(Pre'v. Sanitation Permit# .....-...........---•_--__--•..............Date __..•-----.:..:.....__...:-------- ) Septic Tank (Specify, Requirements) .........................,............................................... ._................ Disposal Field (Specify Requirements) ........--•--•----------•-=--- .T_••-•..... ........... ........... _..._____.___ 3 ......... _ ___ ......................................•-__.__..-___-_-......._.___.._____.,, ......._....... _..-.._......_._.._.._..__.._._.....-_..._....___._.-. - ..............................•--- ............................ _... ............................................__--_----____.....-_........................-_--_ ---..___.......... (Draw existing and required addition on reverse side) r I hereby certify thatI have prepared this application and that the work will, be done In accordance with Son Joaquin County Ordinances, State tours;.and Rules and Regulations of the San .Joaquin Local`Health District. Hama owner or licen- sed agents signature certifies the follawing: "I certify that in the performance of the work for'which this permit is issued, I shall not, lay any person In such manner r` as to beco a subs # to Workman's Com ensation laws of"California:" Signed . + ---• � ............... Owner + By _• (if other than owner) --- Title ----- $ T FOR DEPARTMENT DISE ONLY APPLICATION ACCEPTED BY ------- . ... ..�` ----- --------------•:--•---:.... DATER .I ...... . _... ....... -- --.... ; BUILDING PERMIT ISSUED ............ � D E ...._..... ADDITIONAL COMMENTS ........ ................... .•- -- , -- - _..---.•------- ..... __�.. - ..._....-- ___ _ .. .................:.............. ------------------------------ •�..- final inspection by: ......... ._..- -•••.. ................Date .-- ..... . __ ER 13 2h 1'6Rev. 5KSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7G 3M r