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F }OFHCE (}SE:1 AOR OFFICE USE: APPLICATION FOR SANITATION ERMIT t h ? i------------------------ 7 y��/ , A. �. (Complete in Triplicate} Permit No.__._7_`._._-_._ , Date Issued-_ '- -_--- 7 ►` ''�` lam._-____ This Permit Expires T Year From.'Dgte Issued J Application is hereby made to the San Joaquin Local Health District for a per> it to construct and,install the work herein described, This application is made,in complionee ,with County Ordinance No.549 and existing Rules and Regulations: R � � , . ------------ - - JOB ADDRESS/ OC TION __ �t✓ �r .`__-__,_=--•CI=NSUS TRACT- _._._ f . . �ti� Owner s�l�fame - ----------Phone---------------- _ . r Address- - �j F,' E City ZiP '7 Contractor s�Name��• �� ---l -Sod/_�.- - -------- s�� c3 - _---. 'C�- License #_c -?'Z� Phone i• Install atIorwill•starve ll Residence"j.]c/Apartmeni House❑ Commercial [❑ Trailer Court ❑ {) x Motel ❑ Other------------------------ Number ---- --------- ---Number of living units:_ ` _ �a�Number of bedrooms: arbage GrinderLot Size- __ :_ __------ c Water Supply: Public Sygtem and name ---- °-, ._- --. s .------------------ _-- _- _ Character of soil:to a depth of 3 feet Sand ❑ Silt.❑ Clay ❑„ Pe'at ] Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe,❑ 5F II.Material__.__.-----If yes, type---------- - --- - (Plot plan, showing size of lot, location of system in relatioh4oells, builbings, etc, inuSt .placed on reverse side.) NEW INSTALLATION: (No'septic tank or seepage pit permitted if public sewer is available�v✓ithin 200 feet,] _. i W PACKAGE TREATMENT [ ] SEPTIC TANK' ( ]' ' "_ :_-__ _ _________--: _ __ r_�^_ Liquid Depth._ ------ Size } ] Capacity '-------- Type-_ ___ :--':.-Mafarial� _ No,.-Compartments ----------------------- Distance ` i � _ �. Prop. Line--- ------------------- � { - Distance.to nearest: Welt- -- ---------------------------•=---- Fo n`dation -- ------ D' Box--. - Length of each line. :,TotaL�Length. --- LEACHlN LINE [ ] 'No. o Lines- Type Filter Material_________-----------Depth Filter Material------- ------______________ ----------------------4 Distance to nearest: Wel!________________________-_ Foundation___ __.{_ __-___-- ------------------------------------ SEEPAGE . ... .- p t — ---Property Li ---- - - ;, � ane __ ___. . r [ ] De th--------------- Diameter------- Number -_--- ---- ------------- Rock Filled Yes ❑ No ❑ -1 SEEPAGE PIT Numb . i Water Table,De th._-•=------; '-------------Rock Size----------------------------------------------- q Distance to nearest: Well.. ___ _ P • � Founda#ion � � r Line i REPAIR/ADDITI N { r --- - ---- ---- S -) _ O P ev. Sanitation•Permit#___. �„° * � �'= a- 'Date_"`_'•_ :_'_ Septic Tank'{Specify Requirerrients) __________ ---------------------------_____ Disposal Field (Specify Requirements)-_ _ ----------------------- ' l -- ------ --------- -- - -- ---------- -------- ----- ---------- - -- -------- ----- - ------- ------ - ------- --------------- ---- -------------,-------- -------------------- {prjaw existing and'requi'red 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 z signature certifies the following: i { "l certify"that inthe performance'of'tlie work fob which this permit is issued, I'shall not'^eniploy any person in such Manner as to became subject to Workman's Compensation,laws.of• California.'.'. € Signed_ __ t --- Owner ..t/r7 ----� 4 Ti (.Q --- � 't!e y Gh��•-�- _ ,yam (If other than owrier) " FOR'DEPARTMENT USE ONLY.'- { APPLICATION ACCEPTED BY---- f----. 1- - ------- ---------- ------- -- DATE. -7 ----- ------ f DIVISION OF LAND NUMBER -------- ................. --------------------- ----DATE------------- _------------ i ADDITIONAL COMMENTS -r' r------ -- --------------------------------------- --------------- --------------------------------- - --- ------------------------- - __________________________________ _ ______ ____- ----------_ -----7-.-----_ -_-- =- - Dote cp ---- As13 241,677 JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M'