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1FOR OFFICE USE: FOR OFFICE USE:. APPLICATION FOR SANITATION PERMIT .......... ........... -- --•..--• (Complete in Triplicate) Permit No..7T:.. .W ,•5..... t , Date lssued.��rpf:�i� ....................... •••• --••_••..' - - - - .--...... 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,instaTl a erein described. s This application is made in compliance with County Ordinance a. 549 and existing Rules and Regulations: --._.dam/ i l�..._ ._ WeAt*..?4�....CENSUS TRACT.-.._ .3� iaWt!1 � JOB ADDRESS/LOCATION �,R/ ' . .__....... Owner's Name.... . !`r q!a pJ .l✓ . ..... ----------------....... ..... ----- --- ... --- Phone.... ......... Address .._._ i� i .......A. /. ;r--- --"------- _......._.City-- � d. 7 f ...... Zip-- `� Contractor's Name.......1;., 11 '__...----r A-M- 4-4---- -- -- ............License Phone- Instal latioh hone Installation .will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] otel ❑ Other7:r . ' • ............ Numb er of living units:......`-------Number of bedrooms._.�3_._.Garbage Grinder------------Lot Size............................. Wafer Supply: Public System and name.--- L0,11'O-i-xi. Private Character --- -- -- Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ w Peat 0 Sandy Loam Q Clay Loam ❑ Hardpan ❑ Adobe Fill Material._ .... ....If yes, type------------------------------.. I [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] ' r NEW INSTALLATION. [No septic tank or seepage .pit permitted •f public sewer is available within 200 feet,} / !/ t PACKAGE TREATMENT [ ] SEPTIC TANK [ I Size. /� Liquid Depth. ------------ Capacity ------•--- Capacity... '_ ��-.-`Typel*Z...............Material----#fiOfG��.;No. Compartments............Z..................... i� Distance to nearest: i Well.`.----Uf ...... . Prop .L.i.n1e_T.d ....... .LEACHING LINE No. of Lines...._.---------------.-.Length of each line...... Tot Length ...... ..__._ 'D' Box-...........Type Filter Material..-- -- ---.. ..-..Depth Filter Material..................... Distance to nearest: Well__-f11f�t�kf�p{,., .'.Foundation----- -- '�---.........Property Line._.:___.... ._ _..:,;_..... SEEPAGE-PIT j .] Depth..a;�..-Diameter....44---------Number.._.-'-- `�__________________ Rock Filled Yes Ill E]Water Table Depth----------------------- ------- -- -- --------.......Rock Size.------. - ........................... Distance to nearest: Well------------------------ --- Foundation.......---------.-........Prop. Line.-----= REPAIR/ADDITION [Prev. Sanitation Permit#----------- -----^.-..... -- --------_Date-----------............I—---- -.--.'-.-----'1 Septic Tank (Specify Requirements).......................... » . bisposal field [Specify Requirements]. = ----- --------------------- ----- ------------------------------ ----------- [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 signature certifies the following: 6 "I certify that in the performance of the work for which this permit is issued, I shall note employ any person in such manner os to become .subject to Workmqn' Co ensat bbW laws of California." l Signed...-- ..... ...... .----------Owner --------- By- - ---------------- ---- --Title--- --------------------- ------ -- ----- (If other than owner) 'k FO DEPARTMENT-US ONLY APPLICATION ACCEPTED BY-------- -- - ------------- DATE ... .. 27. - -- DIVISION OF LAND NUMBER'..... ........ = :. . -- --- ---:- -----------...-- - DATE .......... ----- ADDITIONAL COMMENTS..:.......... .. ...... ....................: . ------ ----- a --- ----- ----------- ------------- ------- ----- ---------- -- -- ... . --- --------------------- ------- ------- ----- ------------ ---- -------------------I------------------ ........------I-------- .......... ... ... Final -- -•-- Final-lnspecfion b -- ---Date................ ... EH 13 24F&S,21677.REV: 7/76 3M SAN JOAQUIN LOCAL HEALTH DISTRICT