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FOR OFFICE USE: FOR OFFICE USE: ,,PLICATION FOR SANITATION PERMIT ti/ /Zf- - Permit No.-- �4 -------- --- p n Triplicate) --- C .�i- �G (Com tete i Date Issued--- -..__.. .---.__._..__...._.__ .. _ - __- -. This-Permit-Expires'I 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 applic6tion-is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: aQf/r AA JOB ADDRESS/LOCATION -...... -. . ... = )fir- why--- - 3- -- - - CENSUS TRACT - - Owner's Name.--- -gaq-41r—---------I¢r�t�fei' - -- - - - - - Phone 50 - $TtZ- Address ''lei Sa -- `Crrycl(ew--Rail ci�y Trsscy zip -- Contractors Name -__ 4Cr�}'J�f'l__� VOW- _-_ -----------License # 40—Ij Phone$-;0 /A/. Installation will serve: Residence ,❑ ApartmWt Houseo - Commercial JS Trailer Court ❑ Motel ❑ Other....----`-------------------------------- Number of living units:...... ......_Number of bedrooms----- -----.Garbage Grinder_ ---------Lot Size__------------------ ._----------- ---. 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 Material_._..__.If yes,type---------------------------_... (Plot plan, showing size of lot, locdtion 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 [ ] Size.". _--._._-__--_--.-.---__-------Liquid Dep ._._..__._.. ` Capacity-/f.Gt?O..----Type Ael. . -XMaterial GOwIq --- No. Compartments__ ip !` -- --- Distance to nearest: Well .. Oo Foundation..SD --- --------Prop. Line o, LEACHING LINE [ ] No. of Lines. A✓4 ___ __.Length of each ling /mo----------- -- Total Length Asad------------------ 'D' ._. _'D' Box ........_. Material Afi/'f ®§e� pth Filter Material . O� 1' ..Founpati6n. �r .__ Property Line_ l.SO' i Distance to nearest: Well �-_._ _ --- SEEPAGE PIT [ ] Depth__... _--__Diameter __ _ Number -- _ _ Rock Filled Yes ❑ No ❑' Water Table Depth-------. __- Rock Sizer _. ---- ___- -Foundation.:. _-- Prop. Line ___.. Distance to nearest: Well._.._______ _-- - P• - REPAIR/ADDITION (Prev. Sanitation Permit#---____.---------_------------ ....___- -- Date.____ --------- ..::_.,_--_.:.-] Septic Tank (Specify Requirements). ----------- _ -- - -- -------- - - ------------------------ - Disposal Field (Specify Requirements) ......... . ....._...... ..._ -------- . - -------- - --------- ---------------------------------- ------------------------------------------------------ --------------------------------------------------------------------------------------........ ----(--------- ------------ -._.------------- ----------- _...--- -----' -� ----- -------- ---_- ---------l Draw existing and required addition on reverse side) ` 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Lows, and Rules and •itegulations of; the San Joaquirk'Local Health Disfriit. 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 Workman's Compensation laws of California." Signed._, A+7'1,O.tY1---- ---�91-,ey -------------..._------------Owne. BY --------- ---- -------- - -- ----- ----------- Title... . - - --- . ---- - .. .. - -- - ...-- Pother than owner) FOR DEPARTMENT USEONLY APPLICATION ACCEPTED BY. - - --------- ------- ------DATE-- -------- ----- ---- DIVISION OF LAND NUMBER-------------------- .---------------- + __ DATnE-_.----- ADDITIONAL COMMEN S------ _ o _.� n� �_.. .. --- -------------- -------- ----------------- ------- --------- - ---------- ----------------------- ----------------- ---- -- --------------- ----------------------------- - ` -------- -------------------------------._ .----c---------------------------------------------------- - --------------------------------------------- - -------- - ---------- ----------------------- ------------------ - - - - - Final Inspection by:-------- --- - - -------- Date------------------- -�"`..___---------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F83 21677 REV. 7/76 3M