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FOR OFFICE USE: FOR OFFICE USE: �- APPLICATION FOR SANITATION PERMIT yq Permit No... .L-:'!. 'S (Complete in Triplicate) ----------- Date ---------------------------------------------------- This Permit Expires 1 Year From Date Issued Application is bereb made to the San Joaquin ocaL" "'1"I A istrict for a mit 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 --.1p6o}��..- © _' r!`�.Ajd---AVl1r. 41� 7 .--•-------------------.CENSUS TRACT......... ......-------.-----..-- Owner's Name ...D( fJL. .. ...1�.e-CG< --•-- ---- Phone. ....... ....... Address-..._ . _ .� - IL.POrA)I_CA . ._...... ............City;-. 0 t..00- Zip + - --------------- Contractor's Name...-------.�Awe. �. --....-----• -- -- --.. ----- License #.. tPl Phone.. Installation will serve: Residencop Apartment HouseComm rcial ElTrailer Court ❑ Motel Other_.. � J� iP- dhiGL► ��' A Number of living units:___-1..---------Number of bedrooms..r2—.....Garbage GrinderAU'U"'..Lot Size----4.!.- -- ... ...- Water Supply: Public System and name-__--.__------- ----------- --------------Private Character of soil to a depth of 3 feet: Sand 54- Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ I 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.) NEW INSTALLATION: (No septic tank or` seepage pit permitted if public sewer i avails e ithin 0 feet,) 0 PACKAGE TREATMENT [ j SEPTIC TANKQ Size...... 10, 111 -- - - �. r 1 id Depth_,- Ow ..._... ....... ..... ents.-_.-.Z' J .... Capacity .`2ATyper.,e .. r --- -- - Distance to nearest: Well-.._-+ -_ ---.--- -.Foundation..__1*10 ----.- -- ...Prop. Line-._15-- ------ LEACHING LINE I 1 No. of Lines ..........Length ofeach in Total Length al � > � ---...Type Filter Materpth Filter Material.119. _. �.......-. ........�- ----- -- -.--. D' Box - ..._...Foundation. .. _ Property,Line...`S - --- Ga Distance to nearest: Well.... SE Depth...._.. ......Diameter.S-G7--......Number ----------------- ------------- Rack Filled Yes ❑ No ❑ Water Table Depth--- •------•-- ---- -----------------------Rock Size. --- . __ -------- ---- - Distance to nearest: Well---I----------- - ---------- ------Foundation_........... ......Prop. Line.------ .......... REPAIR/ADDITION (Prev, Sanitation Permit#........_...................... .. .. ..... --..Date.... :........ --------- -------------) Septic Tank (Specify Requirements)- -- - .-------- Disposal Field (Specify Requirementsi......_...------------- ....-...----------------------------- -= _= l ! (Draw existing and required addition on reverse side)' I 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: "I certify that in the performance,of the work for wh rh this permit is issued, I shall not employ any person in such manner as p to becomes bject to *Workman's C pensation laws of. California." ` -. Owner Signed :- By w F . .�r Title...................... f (If other thari owner) FOR DEPARTMENT USE ONLY. .. APPLICATION ACCEPTED BY.. . == ........ .. ...... ......DATE .. . .._. '4 .. ---------------- DIVISION OF LAND NUMBE -- -- DATE..... ADDITIONAL COMMENTS_--------------------.------ ...... ------=----------- .......... ...... .......... -- --....-----------•- .. .... ------------ ---- -- ---------- - -- ....-- -- --- ' ------. ------. ---------- ---------•..... "_ -- ------- --.....-- =-- ---- -- ---------•--- •---------- -- • --------------- i Final Inspdction b -------------------- ----- ..Date... y:: -,- - - --�- - .. - ------- -- F&S 21677 REV. 7/76 3M EH 13 24- — SAN JOAQUIN LOCAL HEALTH DISTRICT