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FOR OFFICE USE: - _ _ APPLICATION FOR SANITATION PERMIT 'r -_ ............... / }( ........ This Permit Expires 1 Year From Date Issued Date Issued ................................................ c Application is hereby made to the San Joaquin Local Health District for a permit to ccn;truct and install the work herein described. This application is made in complionc^ with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._J.A.C.00i....M;XR.S........BH.{R.K....._.__.... ........ ...CENSUS TRAM ........ <, Owner's Nome. ....CI..Tr_..QF..... LVELZ[ / .!J.K.......................................................Phone..... d�7..1.'.,�.:r7_. ..... ( Address T D7 3..... . . .......................................City ...Rid . R13A.N.K.......................... ._Contractor';Name ! .r .. M 4..DQI�[/jLf�..................... t�2.._License# 1_35.16,711.. Phone s!5',37.�8Ei.. ... O - r - Installation:will serve. - - Residence[]Apartment House.❑ Commercial ❑Tralle_r Court ❑[.. - Motel ❑Other.CLTiY._Pf.IRK............ Y w Number of living units:.....^.... Number of bedrooms Grinder ...r..... Lot Size ,. t CJ.-V_ s Water Supply: Public System and name ._CJ.- ..OF.::R1):.F_R 13 f'�K...............................................Private ❑ Character of soil to a depth of 3 feet: Sand 0 Silt ElClay ElPeat[In� Sandy Loam gr<Clay Loam❑ i Hardpan E] Adobe E-1FillMaterial 1.Y.O... If yes,type........._....:............ .t (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 pr ublic sewer is available within 200 feet,) _ ' ' t '/ t S PACKAGE TREATMENT [ ) SEPTIC TAy j� - Size. X..S.. s[2 .a.::Q(fj..:. Liquld,Depth ......91.............. � Capacity'l:.✓.200.y. Type CyLterial...CONC._.. No. Compartments .. . — I/ ......... Distance to nearest Well C.W...................Foundation ...R ............. Prop.Line.. .... LEACH!NG LINE [/T/No. of Lines ..._ ......... Length of each line. . . A00 ..... .. Total Length,.../010 .... I� y D"Fiox�!F_ S n Type Filter Material . Q.C:K---Depth Filter Material .......I�............................... i Distance to nearest: Well ..__C,,_1A.1_..,.. Foundation __lQ --...._... Property Lipa N...... SEEPAGE PIT [ ) Depth � __r_:.r.r Diameter Numbe• . ... Rock Filled j Yes ❑ No Q Water Table Depth .....................................Rock Size ................................ l ` Distance to nearest: Well ........................................Foundation .................... Prop. Line :........ .......... REPAIR/ADDITION(Prev. Sanitation Permit# . .. . I_ �. r date 'I� ' .. . ......I Septic Tank(Specify Regaeements) - ..... .. t l l ! ................ �� Disposal Field (Specify Requirements) ........................... .. ... .................. ..._.._ ............. .._..._. ........... . ...._. .................. . ...... . . . .... .............1. ....._. ._....._.. ......_ ..... __ _._.._ ..._.__ ._ ... ... . .. . .... --- . . -. (Draw existing and required addition on reverse side) is 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, anclAwles and Regulations of the San Joaquin LOtaf Health District. Hetes owner sur Ilan- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is Issued,'I shall mot employ any person In such manner as to become sublairt to Workmcmpensatio la of California." Signed r .. .. .e /j. ...._.._...... Owner By _..__ _.._ ___... ._ ... .. Title .. . . . (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY T• p?.O ___. _ __... . _..._._.... ......._. DAT[.._. 0.17.7.. . ........ ..... BUILDING PERMIT ISSUED _ __. ._ .. ._. .........DATE .__._ . . " ADDITIONAL COMMENTS �e ...._. .. - ..... .. ............ .... . . � 0F.nol ln.pec:.. / rjl� / . r •i'<'. SAN JOAQUIN LOCAL HEALTH DISTRICT w:t''S,."k"s'.' �iL•j',ya{'�S.$a'.+ `' *Y'..,, y� E, N. 9 1-'S8 Rev. 5M,