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i + FOR OFFICE USE: FOR OFFICE USE: APPLICATION-FOR SANITATION PERMIT ------ -- --- --- 7 lit ) 6l/ f�14,"1"1 / (Complete in Triplicate) Permit No... " ..._-_____ -------- -------/---------- --------�( � � 7 Gid G L Date Issued._?= � � -`7f /-7-6G--l^!". 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 and existing Rules and Regulations: JOB ADDRESS/LOCATION - --- 4 --- /----------------•L --------- --------e09---CENSUS TRACT---------------------------- Owner's Name---------------- "7 ----------- --------- - - Phone Address" ." 30 - F` Y ��,;�--- Zip ---------- -- Contractor's Name-------10""Iel A; _�- ------- �� , - --------------License #--2N,5' -"ue-&~ one-. _7'r_ _ "L Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---/ 1d__ ___�s -`�'� Number of living units-----------------Number of bedrooms.. _. Garbage Grinder------------Lot Size__-----------------------___ _-----_-____---------- Water Supply: Public System and name= :. -------- ------- ---------------- -------------t----- -----,----------------------------------------------Private Character of soil to a depth of 3 feet: Sand Silt ❑ Clay ❑ Peat❑ Sandy L am% A Clay Loam ❑ ' Hardpan ] Adobe❑ Fill Material---------._If yes, type'._ .,�r------------------ (Plot """""." Q -------- (Plot plan, showing isize 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 - "O �� .�+ [ ] Size---- --- f-----------Liquid Depth. ---------------------- Capacity_ Type- ------------- ---- -- =: rn __No..Copartments-----.��-Vis_------------- [2-C'r Q----- .�PJ�J�'h'C_Material--------' ------- K Distance to nearest: Well------Ile-e�----------__f-----------Foundation."/.S'- ------_Prop. Line---- G g_-_"----_N LEACHING LINE �' ' [ ] No. of Lines____--"" --_---- Length of each line.__,-- �. --: - g _ �. / �-�•�y�.- -.Total Length.-vi--� j-d------------- D' 8ox._./-.-Type Filter Material`""r __ "_Depth Filter Material"""_-"""._ _/""."______"""""-"" _ ------ ----------- Distance to nearest: Well""." Q C ,;_____�Foun.dation-.-----_._-----------------Property Line------------------------.-____.-.. t 1 ; SEEPAGE PIT [ ] Depth.-..__---------Diameter--------------------Number_____4-------- -_---------_-- Rock Filled Yes ❑ No WaterTable Depth-----------------------------------------------t= ---Rock.lSize------------------------------------------------ Distance to nearest: Well---------------------------------------=---Fouridation--------------------------Prop, Line--------------------- -- �.. REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------"_-_ --------Date ") Septic Tank (Specify Requirements[------- ------------- ---- -------------------------------'" =k Disposal Field (Specify Requirements) ---------------------- -------------------- ..- ! - --------------------- I - ----------------------- --------------------------- -------- ---------- ------ ---- --------------------- -- • -� (Drow,.existing and required addition on reverse side) a � I hereby certify that I have prepared-this application and that the work wjill 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 Wor mans Compensation laws of California." Signed ----------0114FAP�--y--,-�_ - ---- -----Owner BY r` •!f'------------------------ - --- 7itie....ter/' -`.` �,-------- -- _" � -------------------------------- (If other than owner) FOR DEPARTMENT'USE ONLY APPLICATION ACCEPTED BY--- --- f �DATE DIVISION OF LAND NUMBER -------- ... ADDITIONALCOMMENTS --- --------------------------------------------------- ---- --- --------------------------------------- ---- ---------------------- ------------------------------------ --------------------- --------------------------------------------;X1 --- ------------------------------------- ---------------------------- ----------------------- Final Inspection bY:--------- Date 7 ~ J EH 13 24 SAN JOAQEJI LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M