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FOR OFFICE USE: as ,1c�y _ 10.Do fwd ��zrlo� APPLICATION FOR SANITATION PER FOR OFFICE USE: •----.. { 7 (Complete in Triplicate) Permit No............. . ...•.- •. This Permit Expires I Year From Date Issued Date Issued_- .:� 7d✓ Application is hereby made to the San Joaquin Local Health District for a permi This application is made in compliance with County Ordinance t to construct and install the work herein described. No, 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.,.�" -�- . . Owner's Name .. ._ erfot)_- A...- -------- - - - -- �-------•-------- - ----,CENSUS TRACT--------•- - ..... VCslk W �. ---....- _ ----. ----.Phon Address.-,-y 1 ._ . ... . �_,_. �G,G ... .......-- - - CirY- c- -----• ......_ .....Zip---9' 0_;x------•. Contractor's Name....�..._�,�,_-,-_ _ V�-�- . . . --..License #..` -0 - �..'�_. .Phone.... r` Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_ g units:D Number of living r � DMI 4-eAumber of bedrooms..-T7=Garbage Grinder-—.----..Lot Size t Water Supply: Public System and name--..�Q-��:j�c»r�l�:-G� �� i •----- --- ----- -Private ElCharacter of soil to a depth of 3 feet: Sand ❑ Silt ❑ Cla y.❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AclobeX Fill Material.. If es, t - Y Ype--. ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK (A J Imo' Size. • ------- ......Liquid Depth.__,. ..... ....... ... Capacity. -------TYpe-.C§KC)'-14Material----------_---------------No. Comportments..-.- � Distance ton _rest: Well-._.� _--. -._,--- Foundation-.--_ f / A0. . Prop. Line_ LEACHING LINE --�--�- [" No. of Lines v Length of each line.---- d------------- -- Total Length .. ----.. (3�-.. 'D' Box---- --... Type Filter Material...flOC46"-.Depth Filter Material......lg cr ---- Distance to nearest: Well-- t +�.-.-�—.....-Foundation---�0------------ --Property Line---_s ..... ---- - SEEPAGE PIT [� Depth- Diameter... ---.Number...___ _ Rock Filled Yes air' No❑ i Water Table Depth...---...--0-V-�--------- -----------------__Rock Size.__/ �. X- /.AM i Distance to nearest: Well.-.__0 00f i 0 --- ------ ------ ------Foundation---- ,0. ...... _...Pre Line-. p• -------- REPAIR/ADDITION (Prev. Sanitation Permit#------------------•__--_-..-.__ Septic Tank (Specify Requirements)......_- _..-- ae ----_--- - r Disposal Field (Specify Requirements).- -----._. .Q_�_ - 1Z4 ..-.-------•------- ----• -.. ---------------------------------*------------------------ ----------------------------•-----------------.....__ - ---- •--------------. -------------- (Draw existing and required addition on 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 Health District, Home owner or licensed ts signature certifies the following: agen "I certify that in the performance of the work for which this permit is issued 1 shall not employ o become subject to Workm n's Compensation laws of California." p Y any person in such manner as >igned---- ...._ Owner I BY•---R--•- --- - - --- ----- - -------- •---------- -.... ---� -.. Title..._ . (If other than owner) F EPARTMENT USA ONLY APPLICATION ACCEPTED B �...- ......... .-. ------ --------------------- DATE 7 )IVISION OF LAND NUMBER......... DATE. ADDITIONAL COMMENTS__..- - - .IV...------- .._. --- ---- . -.-a, = K 33... ------------- ------ --....._------ ---•-•- .... anal Inspection by: ....... - r . m D f ! - a e.- H 13 sa SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REC/r 71'76 3M