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FOR OFFICE USE: : APPLICATION FOR SANITATION PERMIT FOR OFFICE USE (Complete in Triplicate) Permit No. . Date lssued..r:_3f-. , -. This Permit Expires 1 ear From Date Issued CIA Application is hereby made-to.the Sdh'36a uin Lo al Health District or a perAlt to co ssttruct and li stall the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:. JOB ADDRESS/LOCATION.:--- -------------CENSUS TRACT........... Owner's Name...: _ /� '- --- _/_5::. /�-r✓..�.�.T� � -4-. fP9W /- VrS ��c,�7"-C3 Address -j►�r adX. . .�------ - ---- -- - - City 77 _... ZIP ------ . f Contractor's Name._ L� ...-.- ►/[L�¢/�/f� ,[ �/ �r License #_ _f�. .Phone._ �_-_.f�_4- f. I Installation will serve: ij Residence [] Apartment House Commercial ❑ Trailer Court ❑ Motel Other_..- f}lCfQfJ��---..-.1Q f',EAA9[.,Q �ll.Ylf'f't V�'N Number of living units:..t_ -__.'_Number of bedrooms....&....Garbage Grinder___, ...Lot Size------- -'.-- Water Supply: PiJbli system and n6me —:. "* Private} ------ ....... . ...... d 1. Character of sail to a depth of 3 feet: Sand ❑ - Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam f Hardpan ❑ Adobe ❑ Fill Material - -... ....If yes, type..... ---------- (Plot ------(Plot plan, showing size of lot,,location of system in relation to wells, buildings,etc,musty be placed on reverse side.) NEW INSTALLATION: '(Nn-1,9ptic7tank or—seepage pit permitted if public sewer-is available within 200 feet,{ PACKAGE TREATMENT [ ) SEPTIC TANKS Size - }(.. --.2�-- ..--- Liquid Depth..:? .•.._... --- ...� F�� ,' Capacity-=�e l��----=TYPe ��-. TMater.sal-C .YIf�_�---•--.:No. Compartments....___ ----------------- Distance to nearest: Well_:-`-.�.�D...- Foundat!ort.' .l_..:......:..Prop. Line...: ..._---( t LEACHING LINE [ j No, of Lines ..... '�: tLen th of each line._-' '' { �------- ------ g �40-- - Total Length D' box Type FilterMaterial..... Depth Filter Material. ............. i Distance to nearest: Wel.l_-..----.-lj?jO. Foundation----.: r_'........Property Line._.. .:.�..._..._ SEEPAGE PIT [ ) Depth..��._Diameter.._.�3.:. Number___..../_____________________ Rock Filled Yes [�,/ Na , I Water Table Depth----------- _--- -- = Rock Size----......._.... . . . Distance to nearest: Well.-.../X;S _ .....................Foundation. .._Prop. Line-- ---_-- t REPAIR/ADDITION (Prev. Sanitation Permit#_,._.-_-.--.__:- Septic Tank (Specify Requirements).---- ----- ... .. ? Disposal field (Specify RequirementsJ........ ----- ------ -- -- -- -... - '* k (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 Coun 'Ordinances, State Laws, -and Rules and Regulations of the San Joaquin' Local Health District. Home owner or licensed agents signature certifies the followings:-: "I certify than in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become sub' to,W rkman's Compensaiti ow of California." Signed lri�a�Cr R% f' = -Owner By - - --- --------------.. .. . ......... .,!Title.. -_ {If ether t , caner) F DEPAR E USE NLY` APPLICATION ACCEPTED BY---------- �C!. ..._. .-. t^!L:. DATE ..... .: . 1. ..: ..........._ .... DIVISION OF LAND NUMBER......'.... -..- - . .................DATE ----- - ADDITIONAL COMMENTS- - .............. .. ------------ .. • ------- .. . .- ............. -- ..--_. .._..-- ..... } Final Inspection by:.. � � ---- ..- - ------ -- ---- -- Date..._�, ^:..... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s'21e77 Rev. 7/76 inn F y s