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T FOR OFFICE USE: L OFFICE USE: APPLICATION FOR SANITATION PERMIT No. -Do (Complete in Triplicate)--------------------- sued..::f '4 I•_�/_-�..I-....--...-- This Permit Expires I Year From 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 ith Count Ord'n e No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - - _. ---- 1 -.....1 9W IW-V. CENSUS TRACT_--.. -_------ -----.+ t�. - L'c� ��4(L - ....--- Phone- r3� ,Irk Owner's Name /---- .- ,r �9 Address l Q 1xCr�► ,P"�� ----- Ali1[.c; - ._.City...... lkl .1. ----- Z 91, •' DVS`.. Contractor's Name__.-- -v .�► J*. a� '% -- -- License #_3.4./-•A�7-Phone_..-s3I-- 8"98.. . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.-- -- --- ---- - ------ Number of living units:.---- _......_Number of bedrooms...3--- Garbage Grinder."®"-Lot Size-..---- Water Supply: Public System and name. ------ ..-.----- --------•--""--""---" ------ _.._....-------.--------Private .""-------------- Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay K 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 placed on reverse side.) P NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ..:-------- - nl PACKAGE TREATMENT [ ) SEPTIC TANK [1,1/ Size.__ - ----- Li ------C quid Depth th -------- Capacity-./-a..®O-----Type--•--•----- -� Mate �. �rlal--- ff - -No. Compartments.......14----- Foundation _ undation...�r - _-... -_ . Prop. Line./�-- ----......... Distance to nearest: Well.:... 5743------------------ m ,,....// Na. of Lines Length of each line._..._.Q�S7---"."""-"- --Total _. ...... --7 _ ...... S, LEACHING LINE [.J' - - p,�,� 'D' Box... -.._Type Filter Material-<51A ----"depth Filter Material_._".1, ....Jl�XX....AoipA------ ' f ' . ...-- .. Distance to nearest: Well-.-.,4, "_�--- ��_Foundation. ��--------".---Property Line_..-----@_.------ / Rock Filled Yes J� No❑ SEEPAGE PIT [2� Depth---I .....Diameter.. .�3 __Number--- 'r�------"------- Water Table Depth_--_/P4-------%0............ ---- Rock Size. 1 / ._. Distance to nearest: Well-------lod---- Foundation . .._..Prop. Line...._.+ Q. - REPAIR/ADDITION (Prev. Sanitation Permit#"...__._...."-.-.--"-- ..................................._. ......Date............... ------- -- ------ Septic Tank (Specify Requirements)____ .--.-------------- ""-------- -- Disposal Field (Specify Requirements)----- - -------------•-•"--•----- ---------------------------------- ------------------ ------ ----- (Draw existing and required addition on reverse side) I hereby certify that 1 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 signature certifies the 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-- . r - - ----Owner By........ (..� �- - •-----...... Title .ar4 - ---------- --- ----- (If other than owner) F DEPA TMENT 4E ONLY -- -----..DATE---- -- ------ --- -- --- - ---- -------- APPLICATION ACCEPTED BY....... .. . .. ------..DAT - - ---------- - - DIVISION OF LAND NUMBER---------------__.._..------------- ----- ----- ---- -- ---------------------- --- - - -- --- ADDITIONAL COMMENTS_ ---------... ..... ..- �.,� �"f�. f - - --•----• -...........----•-------Date...--- ---L- •�-�� ---- ----- --------- Final Inspection b ............... - S 21677 REV. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT