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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICt: USI: (Complete in Triplicate) Permit N; . - ;----------------- ...-----..... --- - ...__._. .......... .?..`'��.7� . ---- ...... This Permit Expires 1 Year From Date Issued 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . y�� _. I 6'/ �sfJL-' A - -------- ----------- ----------- •---._...----- ----.CENSUS TRACT............ -........:_. Owner's Name.--..er *. �-zlvJ fW-E��. --- ..... Phone...-9--77 Z�6� { - - -- -----'-,---!--- 1 . 11 Address.....s,?D�.-_'lO /�--�`f-.W. ._. � •,i, City---`5 .. ---- ...--- zip f„If ...... f l f .¢ f�/ff5 .t � 4 _� C �:_ '6License #v7 �`�"35 3 _Phon `e _.7` Contractor's Name-_. lir bi Installation will serve; Residence E]%. Apartment House ❑ Commercial`®' Trailer Court 0 Motel ❑ Other_---------------- i. x . v. Number of living units:....... ----- .Number of bedrooms-.I------. _Garbage Grinder__.._--:....Lot Size............... . . .......... Water Supply: Public System and name._ ............. - ---------•-- •------- Private ❑ Character of soil to a depth of 3 feet: Sand E] --Silt ❑ Clay ❑ Peat ❑ Sandy Loam [Q Clay Loam ❑ t Hardpan p ❑ 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,) PACKAGE TREATMENT j } SEPTIC TANK (� ' ""` Size.... �_�� ----------------- -------Liquid Depth..:.:��..--� ------- Capacity.. Z_ Type.-.-/� CT Material....W C., No. Compartments- =-Wz- .............. Distance to nearest: Well................... p� f ----.Foundation...----� --....._.._.Prop. Line............ LEACHING LINE i j� Na. of Lines ------- --- --------- ----Length of each line--.---- - .- --. Total Length ........4/�- 1Material_— .----�� ._. ...--_.. ...- - CI4 th Filter Distance to nearest: . Well............... �......_- ----._-._ �� - .--.-.--. Property ert Line.... ................... SEEPAGE PIT [� Depth.. .� & ----------------....Diameter_..._.T _ .._.Number -------- Rock Filled Y s No } ❑ Vti/ater Table Depth`__..-_ .� .... ................. .. ..... . F. I` - - - ----- - Rock Size._.'3f51._..x. Distance to nearest: Well------.`------ - ----------- ......-oundation------1.. . ....Prop. Line ----.--- REPAIR/ADDITION (Prev. Sanitation Permit# ----------------------------`--- --...------- --....._...._ .. ) j --...... Septic Tank (Specify Requ0ei�iet�----- - - ✓ --=-- ------ --- --------- .-.- Disposal Field (Specify Requirements)..............:......: .......... ------•-------- ------- ---------------- i ' ........ -----• -------------- -- ' f --------------- ----------------- V (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 Ja quin County > Ordinances, State Laws, and_ Ruies—and_Reg.ulations__of_,the .San.Joaquin Lofai',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 o employ any person in such manner as to become subject to Workman's Corinpensatioh laws of California. Signed......_...... - � ------- Owner - ------ - ------ .-- . 1 BY _.----- ------- . 7 t --.... Title. -------- - ---- ?"ice rte............... ... I (!Pother than owner) ` ' R D ARTME T E"ONLY'=z—. > APPLICATION ACCEPTED BY........... .. .. ' / = ...DATE ..--_. --------... DIVISION OF LAND NUMBER...... �.' r�. TE.---... - ..........•---....._ DA ADDITIONAL COMMENTS - -------- ------- -------------------------------- --- -- -- ......... Final lnspecijon by:-- _.:...- �j - - Date EH 13 24 " SAN JOAQUIN LOCAL HE-ALTH DISTRICT Fos 2)b77 REV. 7176 3M