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' OR OFFICE USE: M / APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: ----------------- This Permit Expl'res f Year From Date Issued Date Issued Appliication 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/LOCATION7-r$- 7y-Zj--------- ---'--- L-DU - ------------------ ----------CENSUS TRACT ----�-'----1--�----- -------------- r1, 1'�j�} �1 : --- ---------------- ----------- Owner's Name ... t�AI_RL ____Phon -------------------------------- l� S a f' Address ----2---- --�-----� -------- -�--------��--_��-�?'�----------------------r-•_ City -- �--- -- I Cont Factor's Name ---CA_R.T. = K m'a�-fi r -- License # '' Phone Installation will serve; Residence D<Apartmehi House'❑ Commercial :❑Traile"r Court 1❑ Motel ❑Other = f Num Icer of living units:___..____ Number of bedrooms 3-----Garbage Grinder _ __jF Lot Size --- i Y '' Private [ � L __________ ___'__________._..._____-____________.�___.___-_______f___....._________._._________�...___ Water Supply: Public System and name .__-.___ Char cter;of_soil._to a depthFof 3 feet: Sand❑ Sllt❑ Clay ❑ 'i Peat❑ Sandy Loam;e'Clay Loam E] Hardpan ❑ ..�Adobe Q Fill Material __ C?_ If'yes,type ---------------------------- (Plot plan, shoving size of lot, location of system in relation to wells, buildings, :etc. must be placed on reverse side.) NEW INSTALLATION: f;_,, �� , ,� . '_' - -__.- " (Na septic tank or seepa pit perm�tted if pu^hlic sewer is is within 200 feet,) PACKAGE TREATMENT SEPTlC TANK Size__' - n { 7 --__0--e-��---- ---------- Liquid Depth ---- r�----- Capacity _12-:D_0_.__ Type PREC45-17Mdferia1.CON RT-- -No. Compartments LEACH 'stance to nearest: Well ______50 ____-Foundation ___-1�+'__ t` Pro Line _ p. p 1NG LINE No. of Lines :, " _ Length of each' line-. 'D Total Length ------- �_ 'D' Box Type.Filter-Material -_ p t ��'' _De th Filter Material --_-- f / Distance to nearest: Well ---5Q4:�,;f------- Found6F1on___�Z9__%-�-_--',_ Property Line __5____ _ ___ SEEPAGE PIT [ ] Depth -----_._ ---------- Diameter --------_,!----- NLIm9er - ---- Rock Filled Yes ❑ No C, Water Table' Depth -T^ - Rock Size Distance,to�nearest: Well ----------------------------`.._--_------Foundation ---------- --------- Prop. Line _..._.---------------- l REPAIRfADDITION(Prev. Sanitation-Permit# __._____.____.__-_____ _____ t ---------------•-_-- 1 ae Septw Fr t -.. �t ic Tank (Specify Requirerrients) t ------------------------------ : Displ�osal Field (Specify Requirements) --------------------------------------- ------_------------------------------- 1 ---------------------------------------- ' a -------------------------------------1 :1---- -------- - j�i --------------------------------------- (Draw existing and required additionnreverse side( I hereby certify that I hav4repared this application and that the work will be done iW accordance with San Joaquin County Ordinances, State Lcl"- , and Rules and Regulations of the.Son Joaquin local Health District. Home owner or licen- sed agents sign ure certifies the following: "I certif t ' /the erform of a work for which this permit is issued, I shall not employ any person in such manner as to eco uble to W rk n' ompensation laws of California." r Signe I ------------------------- _-- ------ Owner , I BY ----M------- ------------ --------------------------------------------- -TA-K-0----- Title [If other than owner} -------------------- FOR-DEP..ARTMENT_USE,.ONLY APPLICATION ACCEPTED BY ------ - 1r :_LJ-____ -�--��' DATE / � r�� ADDITIONALCOMMENTS . ----- --- -------------------------------------- ---- ------------Ik------------------------- -----------------------f ------- V - -------- --- Final Irisp ' n by: ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9,I 1-'6$ Rev. 5M ;