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' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: Permit No.,7e.. ,W,57 ------ ------------------------- - (Complete in Triplicate) --- Date Issued_1J/ _S'_'7r ----------- This Permit Expires 1 Year From Date Issued 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: / JOB ADDRESS/LOCATION---- ------ --- CENSUS TRACT--------------------------- !_�-L�d"V- ---�-.._�f�r�-�_ G - - --�. �---�- rN r, �" Phone-- ---------------------- ----------- Owner's Name.------ <V ------1 I._ ---------------------------- y ---. Address-- ---- ( ._ y — Cites fl Zi -------------------------- Address-_...- _ -� -�--�-_�..,�_��.�---- �----- �-rte -- - v- -- _ -� ----- -------� P ---- _ �-Phone- -- --- Contractor shame__... i_-- v-/'�-� �=1.✓I� -- --------License # _ U ------ , Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court E] �F Motel ❑ Other.'. -------------------- ------------------- Z5! . Number of living units:.__ -: --,--Number of_bedrooms---_---j__.__Gobage,,Grindea_.__---.-_Lot Size___-__.__ ---------- N.,$ L _Private Water Supply: Public System and nor e........ `_ = S P, Character of soil to a depth of 3 feef: Sand ❑ Silt❑ Clay E] Peal.`❑: • Sandy Loam ❑ Clay Loam [_1Hardpan Adobe ❑ Fill Material.__--____..If yes, type-------------------------------- i i ` (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 public sewer is available within 200 feet, Size -i/ f� �] Liquid Depth T:_._ PACKAGE TREATMENT [ ] SEPTIC TANK ( ] / --------------------- 4 # Capacity/ C;�&t)- TYPw)*, Cf+7 _Material__------------------ ---No. Compartments - °- ___Foundation__ _f____---- .-Pro Line---"I--------------- - _Distance to nearest: Well—, ------------------- p p' jl .Total Len th----� ------------------------ -- LEACHING LINE I ] No. of Lines.---------------------Length f each line. __..-� -- - '� i 'D' Box----�.-----Type Filter lNaterial_.��C�`eptF,Filter Material-----f ----------------------- z bistance toe st: Well_-- -----Foundation-- ------------------------Property Line----------;----------------------- De th L 6' ____._.Diameter_ v}6- -Number._,-------------------- Rock Filled IYes� No El SEEPAGEjPIT ( ] p WaterTable Depth ---------------------------------------------------------Rock Size-------------------------------------------f---- ;Foundation--=----------- ---------- Prop. Line...------ --------- ------ Distance to nearest: Well._.._______._.__ - I e REPAIR/ADDITION-{P-rev. Sanitation Permit# ------------ -------------------------------------Date--------------------------------------- f f Septic Tank (Specify:Requirements)---------- - -------------------•----------------------------------' - ----------- { 1 :... f "S- ----------------------- Disposal Field (Specify Requirements)---------------------- � _"'►' __` �� t -- -------------------- �•---tet-- ------ ----- ----------------------- ---------- ------------ - ----------- ---------- ------------------------------------- (Draw existing-and required addition on reverse'side) ¢} I hereby#ce that have prepared this application mid•th'at'the 'work will b4,dna a in accordance with San Joaquin County Ordinanc�FState Laws, and Rules and Rec_JIvtions.oft San Joaquin Local Hec(Ith D» ist jic _. meowner or licensed agents signature Certifies the following: "I certify hat in the performance of the work for which this permit is issued, of 'employ any person in such manner as to beco rr> i subiecf toor !,ns mpensation laws of California." Signed__._-_. _/�._r.- -✓.- !r! Owner I ------ I Title.---- ----------------- -------------------- ---------- BY------ ------------- ------------------- r ' ""(I•f other than owner]------------ l --- r l OR DEPART NT4JSE-ONL-Y' 1 ; DATE.---- -- -- -- ---------- ------- APPLICATION ACCEPTED BY- __.____ - -- ------ DATE --- ---------- R .---------------DIVISION OF LAND NUMBE :: - ------------------- - ADDITIONALCGMMNTS-- -- --- -- r --------------- ---- -- --------- -- --- -- ---- --------- ------------------------------------------ - - -- Da - Final Inspection b - ------------------------------------------------------- Z11 ----- te EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M, k