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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...............I........................._.. - Permit No. _7_?-.5. J F (Con1plete in Triplicate) �/ Date Issued .-O......... —72. ..............�'.•K-.. .�.�-....... This Permit Expires 1 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 with County Ordinance No. 549 a d existing Rules and Regulations: ! J `DDRESS/LOCATION �" .rte ��.a-."-.CENSUS TRACT ..... OB Ap `� ............... .. h_/..... Owner's Name _ .!^ ... �`. ....¢ ..� � o' �?•r .....Phone Address _ GI _r ._e. -!- ..�� .1 t_: ....... ................. City ---------------.........,.-"-"-- . ---._ .. Contractor's Name . rr-�_�S .rv�-- ---- 11. ............................-.License �a�l.a-:_. Phone �r .`. Installation will serve: Residence [] Apartment House 2rcommercial ❑Trailer Court 0 Motel ❑Other __------------------.......--•-----------• Number of living units:............ Number of bedrooms ..........._Gar ge Grinder ------ Lot Size ----------- -------------------------------- Water Supply: Public System and name -•-- ..... ----------------------------- I.•-----•--•-•.Private ❑ Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam 0 _ .l Hardpan ❑ Adobe Fill Material ............ If yes,type ........._................... i Y : I IPlot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed onyreverse side.) �)j NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 206-feet,).- �^ b PACKAGE TREATMENT [ 3 SEPTIC TANK I ] Size.... •----------- Liquid Depth ..................I .. Capacity _ `. _ ' .T- Type-. CL impartments . P ty� I_V/ Material ...Foundation Distance to ne rest: Wel{ ---y'Zy— .-_--:. .-•----"--- Prop. Lin .....r-•. ! LEACHING LINE No, of Lines ..._ Length`of-each line.____' _ _ �? '� . Total Length [ � ------- - t_ l 'D' Box -----l.... TypelFilter Material _ .,�~..-;Depth Filter Material .......��______________��......_ ?� ' Distance to nearest-'Well ... "Foundation, ... ...�....... Property Line __._. __..._'.......s SEEPAGE PIT ), Depth ----._.. _---_i. . Diameter ........... Number,- ...__.....__........... Rock Filled Yes No [j ' Water�,Table Depth `- ...........Rock Size 5 ti . • Distance to nearest: Well Foundation ._.... Prop. Line - ----------•--••- REPAlk/ADDfTION(Prev. Sanitation Permit# ............_... .............. ------------ Date .:................................ ) Sepfic Tank (Specify Requirements) . T '' ....:................. ..........---••............----.I—-...---•-- .......... Disposal Feld (Specify Requirements) ---•- / - t�1 �t``f ` _.....5 ..... - I � 0 ; . s. .,, .... �. •-------------------------------------••........................................................ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that'the work will be dans in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations.of the San Joaquin Local Health District. Homo own or Ii County agents ?Rignature certifies the following: ' "I certify t 4 the performance of the work for which-this.permit is issued, I shall not employ aay person in such manner as to beco' a object to War arts o e on laws of Cal€fofnia. f , Signed . .. ............ ............. Owner By .._.._.....�........ ..... .................. `....._....._._.._._........_...._•----.._....__._..Iitle ...... ----........------.. "---....-=- (If.other than owner),,,. � y FOR PARTMENT USE ONLY All t APPLICATION ACCEPTED BY . ►...... ................ . . . . DATE ...... _... ...' ....- ------ BUILDING "PERMIT ISSUED ........................... . ...... ......._. ........'....DATE __.'...._..___..-.._._ ._.. .. _ ADDITIONALCOMMENTS .....................................::�.............................................................................I......I........... .......... I, ..•-•.........................:....... ...................... --------------••-•- - :. * ----•- ¢......------. -•--•-•-•--••. ....... ............ ... ......... ---.-.-. .. ........ ..... ---• - •--•-•........................ ...................................... r----- ----------------- ......• - •....... . ............... ...... Final inspection by: _` ......................................Date --•---2. ... .. SAN JOAQUIN LOCAL HEALTH DISTRICT 13 24 ,__�� oe., rex 7/7232