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FOR,C3FFICF»USE:. APPLICATION FOIZ SANITATION PERMIT ;Complete in Trlpllcatal Permit No. ..7 5'�� ....................................... J� ........ .. . ...... This Permit Expires 1 Year From Date Issued 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 and existing Rules and Regulations: I, JOB ADDRESS/LOCATION ... / Pg.�s C alt .........CENSUS TRACT Owner's Name .___... Phone .............................. ... .................... ..................... ............... Address ..__........ city rn AAITeCA ..............__..........--•-•---•--•----• ----- ........__...-_........1.1, ......._................I.....-----•--- Coritractor'sName -. F_- CARG��e ...............License ,# 2�39p.......P ----- -----------------•---------------......-------------••-- ....... , ............_ Phone ... ..........---._..... ..._. Installation will serve: Residence❑Apartment Housefl Commercial oTroller Court C] Motel []Other...................... Number of living units:_.____... Number of bedrooms .._ ......Garbage Grinder .... Lot Size �CR. .eA. . a. .... .. Water Supply: Public System and name ______________ ......Private Character of soil to a depth.-of-3 feet: Sand ] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan❑ Adobe❑ Fill Mauer#al ............ If yes,type ............... ....... ....: , (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.[ NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 200 feet,} PACKAGE TREATMENT [ } SEPTIC TANK f } Size___ . .............................. ZN id D pth ..................... Capacity TYPe : ------ ----- Material.................. .-. p menta Distance. to nearest: Well ........... .......................Foundoti .... Prop. Line .....................J LEACHING LINE [ j No. of Lines ________________________ Le th of each line,.......... ten th 9 N 'D' Box .._....._... Type Filter M teriol ....................Dept Filter M ........ ._. ..............Distance to nearest: Well ... ................... Foundatio -__--.-..._.-__.. erty Line ._....................�SEEPAGE PIT { J Depth ------•-•----------- Dia er ------ ------- Numbe --.----------. .. Filled Yes ❑ No >p7 Water Table Depth ----- �/e F Size ............................... Ii Distance to nearest: Well ........................................foundation .................... Prop. Line .....................p REPAIR/ADDITION(Prev. Sanitation Permit# .........------------------_---_--------- Date ......................-------- ---------•---.-}- ------. .....-••---•--•-----•---••-----Se tic Tank (Specify Requirements) Disposal Field (Specify Requirements) D D O. fT Ze-,qct .. _.. ...............- ... ...------... . .............. --------- --•-- ----- ----- -------- ------------------- -------- (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 HeW&District. Memo owner or licen- sed 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 -•--------- -•---------------------------- ------------------------------------------------ - Owner By ?-----R. -�� 2�i/c- ---- ----••-•---------•-- �itle .. (if other than owned i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. ,.11% ------------------------••----••----- ------- .•.... DATE 1.. - -...........tw BUILDING PERMIT ISSUED _. DATE --------------------••---------------.._ ----------•--------------------------- ------------ -----.....---•------- ADDITIONAL COMMENTS .-_..._-._-_.:__ ------------------- ------------ ••---------- ------------------•------------•- --------------------- ------------------ ---•-- --.......................................... - Final Inspection by ------------------------• ---------•-------••--------------------..._._-- ---------..----------: ..._- ..... • ---- Date .. ._.. ~' J........... EH 13 2h 1-6f3 -----••--•-•------------------•-----..-.-..---....---------------- >M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M k