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FOR OFFICE USE: =' "= FOR OFFICE Wit; APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit Na.....g'_Jy . ........................................ . .......... •».� Issued.5��dr�9 ................................... . .-•......---- This Permit Expires S Year From Date Issued Date Application is hereby made to-the San Joaquin Local Health District for a permit to construct ond.install the work herein described. This application is made in compliance.with County Ordinance No. 549 and existing Rules and Regulations:. ! 4,�� JOB ADDRESS/LOCATION.... ........... ' CENSUS TRACT................................ Owner's Name......... ._r .^- ...... - .• .......:.......... . . . _ ............................. •-•.-••---...Phone- Address............... ......... ......D..k...........City...... . .Zipi_, ,.r...i..........f.c..i..1..�............. 9 Contractor's Name........X i. ..._�rk......--•---_•-- . . ... ..... . ....License #sr�_-2;.7r��a....Phone.,C�.J:�.:��..... Installation will serve: Residence's Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.......... .......................... ....... Number of living units:--.....,....:.Number of bedrooms..t3.... Garbage Grinder............Lot Size.........T-�J............... '*........................... Private Water Supply: Public System and name.......................:................................:.......•---•-------- ..-...-........-- ------. . Character of soil to a depth of 3 feet: 'S66d ❑ Silt❑ Clay ❑ Peat❑ Sorldy Loam 10Clay loam ❑ r Hardpan [3 Adobe❑ Fill Material._ .... ....If yes, type....��---•- .......�.....-. A (Plot plan, showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.) ' 4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer ii available within 200 feet,) , PACKAGE TREATMENT [ ] SEPTIC TANK [ j Size....._ ..�,%_ ................Liquid Depth..1 F4 ........._- Capacit ------.TYPe / aterial... No. Come�ments....... .... �?.... ... _.�� Distance to nearest: Well.'.__672>.-.. _-7.- . _....Foundati�A:;� .��..... .- Prop. Line...' _ .... LEACHING LINE [ j No. of Lines....... .Length g of each line.....f/ ...�..._......Total Lenges.......pw.fi=+Q•`...............� e -- 'D' Box..�. . n .._...Type Filter MateaL./�.��,� pth Filter Material....... ....- ___........ Distance.to nearest: Well...�..�. . .I....Foundation.....©- ...Property Line.......__ -......�~ SEEPAGE PIT [ ] Depth.......... .....Diameter............... . . Number.............__.__........-------Ni/ Rock Filled Yes ❑ No Water Table Depth............. ................ ...............:.---.....Rock �1ze.:............................................... 4 JV Distance to nearest: Well............... ..;....:....: ifoundation...........................Prop. Line......- ............. REPAIR/ADDITION (Prev. Sanitation Permit#......................./....:... ............ Date_..........I...�...........___----...j Septic Tank (Specify Requirements)........... ... �.._.'.. . ---------- - Disposal Field (Specify Requirements(. _.__..._..-. :1 ' I .......................• (Draw existing and requiredadditidh'reverse side) 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, and Rules and Regulations of the San Joaquin Local Healffi'District: Home owner or licensed agents i signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued; I shall not employ any pers n in such manner as to become su 'ect too0an's Coppensation laws of California." /W 't , ' Signed........._ _!:. .t..... . _-- �S._._. .Owner .. By............ _..._. .. ...-....................................................••----•----.--....._....Title............... ........... ........ ......... .....-._. .._........... ... (if other than owner) ! oe 00 FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY..--• -- . ... ... . ........ ........ .. .......... .. .............. :............•-- .........DATE 7-- ..-.x-77 ._..... .. . DIVISION OF LAND.NUMBER...a:..::.._...,,_ _ . + .......,DAT.E�_;_.;.. ....t.............. ..-...._.•.,:.__ ')ITIONAL COMMENTS..................... .... ._.. ----.....,..--:....... ..................-........ •-• -••---................................................................. .. -.:.... �.,. - i P . ................... ......... _._. ............... ._.......... -•-• --- .................. ..................-..._.. .........._--.._............._........'..............................._.._.............._...................._...... ........................................ ..... .. ... .F... .............................-.................... _-.._......-... Final lnspecnon b _.... y:. ........I................. .._.._...... . .................................. ....Dote..... -...... EH 13 24 f&S 2167e REV. i/76 3M SAN JOAQ IN LOCAL HEALTH DISTRICT (166J11�