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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: _. i (Complete in Triplicate) I Permit No.79.".3 Y.G. 9 ------_ - This Permit Expires 1 Year from Date Issued I Dote Issued.6'�.v.. 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: 1 JOB ADDRESS/LOCATION 40? E. f Lst/. `lJd fir....._ _ ..CENSUS TRACT............... .. Owner's Name . . l*E ./7lvLltp!' /Dlffr�Cl�f/6. S�f�a . Ph ........_ one .. Address....... Do�/ �.../ ET TLEf'1�AIV Li(/ LOO/� _.... ..., ................ City........... .... . _............ .Zip.. Contractor's Name. . .f /t�2/S y/ vc SO�f/ License Installation will serve: Residence [ Apartment House❑ Commercial'Trailer Court C3Motel ❑ Other. .. .... .. . ... .................. Number of living units: ....... Number of bedrooms .. Garbage Grindw............Lot Size......... .. Water Supply: Public System and name _.__ . . . _... ... .. .. _. Private ❑ feet; Sand Silt °v Character of soil to a depth of 3 f L'* ❑ ❑ Clay❑ Peat❑ Sandy loom❑ Clay loam ❑ C t:9 Hardpan ❑ Adobey Fill Materiul . ... If yes,type......................... . �14±1 (Plot plan, showing size of lot location of system in relation to wells, buildings,etc. must be placed on reverse side.) —� r} NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK IN' Size . .. ... 137�� Q. Liquid Depth......sy w f CapacityQOO...._Type...RECT_.. Material.....�O.tJG.......No. Compartments................... .................. Distance to nearest: Well..................... . . . .... . .......Foundatio ... �O i7�. . Prop. Line ......... ` LEACHING LINE (►-j` No. of Lincs ...............Length of each line. .. .. Total length .................. .i D' Box .✓ Type Filter Material...s!�.. ... Depth Filter Material.. ......�8... �. Distance to nearest: Well........................... Foundation.... � ..Property Line......S.. t 5 SEEPAGE PIT [yam Depth..R-r Diameter... O.... .....Number. .......^3........::......`r Rock Filled Yes No❑ M1 Water Table Depth............................... ... .....................Rack Size.....-31�.w.X.��s ` ....................... 1 Distance to nearest: Well...........................................Foundation.....A0..?f' �" Prop. Line.....5...............:. REPAIR/ADDITION (Prev. Sanitation Permit#......... ......................... ...............Date..........._.... .............. Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) •'......... ........ ...... ............................ ....................................... .................................................. .... ........................ .................. (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be'donut in a cordance with San Joaquin County ?' Ordinances, State laws, and Rules and Regulations of the San Joaquin local Health Disct, Home owner or licensed agents r signature certifies the following: ; A "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." f Signed..... Owner B ............... By �` � ............_ .... .. . .. . Title..... ...;!!SF7.� c?-T. !0�.................... . . . . (If other thou owner) f0ft DEPA TMENT USE NLY —_,7r APPLICATION ACCEPTED BY.... . . . t.7/../,44 DATE ...... . —77- . ....._. DIVISION OF LAND NUMBER . .... ...................................... DATE................... . ......... ADDITIONAL COMMENTS ......................................................................... ..... . .. ... . . .. . �....................... .. _ .......................... ..._................................................ ..,... .....:.:............ .... .................................. .........:..;....� ... Final Inspection by: �...... � ... ...........Date..... .. yg EH 12 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 2101 R[v, ens 3