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� tFOR OFFICE USE: �.. � . APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit •---•--•- No. ! -- ................. This Permit Expires t Year From Date Issued Date Issued_7?�-, `- Application is hereby made to.the San Joaquin Local Health District for permit to construct n . v a d,mstall the work herein described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATI ON........�.�6I ....CENSUS TRACT.--- Owner's Name—_-...... h�......_ _ ►�-SSC�� ...................... ------------------- ------.Phone -/(�'"..yy8,3. ` Address------- �— .......... ---------------------------- City 5 7 L?C_ CT !u Zip Contractor's Name.-.... .... -..L ....... . .....License #-. Phone ...... .................... Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ } -❑..`..'Other.:'_„ ' -:'---.~^~--_-- ----------------- ,•� -� j Number of living units:--..............Number of bedrooms.._.2 Garbage Grinder.-PO.. Aot Size-_...6Q , 0 I 00 �,...; y,., (� _ ,� . ---------------- Water Supply: Public System and names-- .... ---._F'Z0t'c_-S-y 4- 'ym•� _ t---------.Private ❑ Character of soil to a}depth of 3 feet: Sand ❑. Silt❑ Clay ❑ Pea't. , Sandy Loam ❑ CI am ❑ G - < r Hardpan E] ' AdobeMaterial . ..-. -.-.lf ype__________ _ _ _ (Plot plan, showing size of lot, location of system-in relation to wells, bu' i ,,.etc: must b laced on reverse side.) NEW INSTALLATION: (No septic tank or epage it permitt ..-se er..is la within 200 feet,) PACKAGE TREA T [ ] , SEPTIC TANK [ .] --.Liquid Depth_.- a Capo .. . ..........Type ---- ------ �a is ..... . - ----------- ------------------- ------ istance to nearer : ':".-... ndation.`.-_. . Pro LEACHING LINE ~ n , j _---.-.... .en each line - �l a Length... Z.�--- ----------- --•.-- --- [ ) No. of Lines _ D' Box Type Filter Material. . - 1, er Material' - - --- Distant to nearest: W ..-..----- dation---i-------`�---• -.,_Property Line. SEEPAGE PIT [ ] De .......... ..... Meter....----..... ---,.Num er-.,__: -__---1-- -- ock Filled Yes ❑ No❑ Water-Tabls..pepth-max = - ........Rock Size -.. . LV Distance to nearest: Well----.._ _ aun a ion--- I J —zy- 73 REPAIR/ADDITION (Prev. Sanitation Permit -7.3`-_ � ._._... . _ .- .Date.-_-ID.-... _. _.. _ - Septic Tank (Specify Requirements)_. _._ © 1F - ------ --- �.... .. Disposal Field (Specify Requirements),..---..-.-.. .F.�S'x,1.4-x- - -------„_ ..-- ... r Le i.3� ¢..,�+t?e �dC # �i .....•----- ---- ------- -- `` ...v-r5----- ------ ---- - W__c ..... 1 --mak . ---- (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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San_Jnaquin-.tocal_Heal_th 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California.” • Signed-. *-- �.,-...ems, �, _= Owner—.--- .A..�_ - --- ,.. 0 By------•... •----- ...... .............. ....... ------.. Title -- -- ------- ...._. --- -------- --- ------- (If other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED E2!� .._ •----------------DATE . �i . . DIVISION OF LAND NUMBER .. .. . ...... DATE-- -------- ----- ........ -----. i ADDITIONAL COMMENTS.. Ns;d ,�t9dN...�..- D- d 41;........... .............. ,, a ,,�. -- -. l - - ... ---------------------- --------- --------------- Final Inspection by:-..-- . ----- ........... ---- ---- ---------------- ---Date....- ------ --- EF{ 13 24 F&S 21677 REV. 7/76 3M SAN JOAQUIN LOCAL HEALTH DISTRICT Ti