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I FQ.R 0i FFICE USE: i APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ------------------------ ----- --------------------- .. (Camplete in Triplicate] Permit No.._74-�......A, -•---•-- -•-•---••----------------- ----------Y--------- _-7� "' This Permit Expires l'Year From Date Issued Date lssued..�r``. 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.- ......e�A. 4_0J. --...6-6110w_CENSUS TRACT. -- Owner's Name.__ R..+b . # ".101. -.... `.' Address...-- -.2" Q.� 4"I�'l . i1 - -_ - ......Phone. � ---� . .. .. . ._ r.. '... . P .: ...............•----- -------- Contractor's Name..� N ;7+73"_ Phone- per b3_]..-.--License # Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer. Court ❑ 0 Other...... - Number of living units:..]---------.__Number of bedrooms--.-4... Garbage Grinder------------Lot Size._ Gr 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 pldced on reverse side.) NEW INSTALLATION: ;(No septic tank or seepage pit pe rmitted.if public sewer is available within 200 feet,] PACKAGE TREATMENT [ } SEPTIC 1 ANIC1t Size.- . ... . ---------•-------•---- -- - ------Liquid Depth.-.5.T......... .. , Capacity... ----TYPe '' •..- material,_._.[�r•G_.----No. Compartments.....��................•-- Distance to-nearest:-Well::-5'0-=-- - 'Foundation:------- - -_ _...... Prop. Line-..............- -- '��""- LEACHING LINE [ ] No, of Lines ...._4--__.___•-.-.-__.Length of each line.--.__+ � -- ------- - Total :Length .....4 ................ -••- 'D' Box-......... Filter Moterial.121EK.__..-Depth Filter Maferiai:.11 -....._ ............. ... Distance to nearest: Well..... �r -..._ ._.. -------------4..Property Line....dd.. ----------____ . SEEPAGE PIT [ Z Depth. - Diameter. Number T io ----- ---- Rock Filled Yes ❑ No❑ Water Table Depth-------------------------------- ---- -----------.-.-..Rock Size-' .. ----------------------- Distance to nearest: Well------------- ------- --------Foundation...........---............Prop. Line.---....__--- REPAIR/ADDITION '(Prey. Sanitation Permit#...--- -- ------ -------Date...:..- -••---.------ j ------ Septic Tank (Specify Requirements)...._._.._------ -------------- ------------ . • --. Disposal Field (Specify Requirements).__..........-- J : ----------- ---------- -" -------••----------•---- --------............... -------------- (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. Home owner or licensed agents 1, signature certifies t1Ye 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.,, ' Signed .---------------- ----Owner By M Titl (If other than owner) .i FOR DEPARTMENT U-SE`ONLY APPLICATION ACCEPTED BY-..__ DATE ... - ------ d.:.._ ` -- DIVISION OF LAND NUMBER-------------- .-- DATE - - - - • --------- -------------� ��------::.-----....---- .....---------- ADDITIONAL COMMENTS.......................... . ••----.... ---------------------------- ....- - ...... --------- ------,.- ------------- -- ----- . Final Inspection by. - to _ Da EH 13 24 SAN.JOAQUIN LOCAL HEALTH DISTRICT F6s 21677 Rev, 7/76 3M