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FOR OFFICE USE: I APPLICATION FOR SANITATION PERM. FOR OFFICE USE: .................................._ . iComplefe in Triplicate) Permit N0-7.9.-3.9 ......................................I................. Date Issued-/✓'79 .... ................... " ............ ..... TI :s Permit Expires 1 Yea- From Date Issued Application is hereby made to the San Joaqu;n 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. ...... ��. . STcry l� A/ .. _..... ` _. .....................".......................CENSUS TRACT.............................. . Owner's Name.... .R...A......192 y.e?'............. ... ............... . ... . . ..........................................Phone .Y .? -/�G8 . ...................... Address.........../..y�9 2 _....... ... LCseyLo.!)�.. ......... •: City.......... .... ..... ..Zip.............................. Contractor's Name.. _ .................. ............... .............. . Phone.S3 / / ........e . . � t; Installation will serve: ResidenceZ Apartment House ❑ Commercia! ❑ Trailer Court ❑ Motel ❑ Other..... . .... ....... . .........__. ....... Number of living units:......./...... Number of bedrooms _:z Garbage Grinder...... . ...Lot Size.... f3crCS Water Supply: Public System and name . _ .. ............. .. _ .__ ......................Private _ Character of soil to a depth of 3 feet: Sand Ll Silt❑ Clay❑ Peat❑ Sandy loarn❑ Clay Loam ° Hurdpan ❑ Adobe ❑ Fill Material ... If yes, type........................... . . (Plot plan, showing size of lot, locatiDn 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,) e PACKAGE TREATMENT [ ) SEPTIC TANK ( ] Size .. .. .... ............................................Liquid Depth .......................... Capacity.��. . . .Type..P!r..C�°sT Material..C4?et-rr...........No. Compartments .x....... . AO ' //n........ Distance to nearest; Well........�......'... .. ... .... .........Foundation . .. . .... . Prop. Line.... ......... LEACHING LINE [ ) No. of Lines ..3-. - ...-.........Length of each line.....fin...................Total Length ./-;!'............................... � 'D' Box I. . Type Filter Material. Depth Filter Material.. :�0.............................. ............... ....... Distance to nearest: Well.......... ..... . . ...... Foundation................... ..... . Property� Line.............. ......... � 3 SEEPAGE PIT (3] Depth.. / Diameter.,.T./....�X�Number .......................... ®Rock Filled `les No ❑ WaterTable Depth............ S ........... .........................Rock Size.../� ........ ............................... Distance to nearest: Well....../.-)0........................... .Foundation . .. .....Prop, Llne....3n..:.... ...... .. REPAIR/ADDITION (Prev. Sanitation Permit#........................... .. ............Date...................... .......................) Septic Tank (Specify Requirements) .......... .................. � .. ...../.. �Nf ....................... Disposal Field (Specify Requirements) •• - ""'""" """'."•-'.".."..'.•.•.• ........... .... ND SGv �� ..CYC �. . .. :'U. e ' ..!.'' ...... .. ......................c...... .... ......... .................... ...... .... . ........... ...... _. _ . ......................................... . ........................ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the wore will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulaticns of the San Joaquin Local Health District. Home owner or licPnf@d agenic j 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..... E; /47vr/�>r (> -Se,V Ownw ��Ilf . Title . .. .........than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. { A, �, ...... .DATE . /r..'�•^•�( - DATE .... ._......... DIVISION OF LAND NUMBER . ........... . ........ . .. .. ADDITIONAL COMMENTS ... .. ................... ........ .. ............. . ......... ...............................I.............. ... ...... ....... ..........I.............. .... ...... ............. .... ................. _ . Final Inspection by: !�. // /'r' , {'.. _ .. ...................._... .. ..Date. F&S-21677 REV. 7/76 3M EH 13 24 SAN JOAQUfN LOCAL HEALTH DISTRICT '_ .