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FOR OFFICE USE: APPLICATION FOR SALTATION PERMIT Permit No. ---- ------------------------ ---7�--�9 S_ • (Complete in Triplicate) ---------- ------------------------------ - ------------- ---_---- This Permit Expires 1 Year From Date Issued Date lssued ./'77 ' p -------- -- --------- --- -------- - --------". q _.,. , , - xi fiihRule Application is herebymade to the San Joaquin Local Health Distrix for a,$ermit. to construct,and� install the work herein described. This application as made in compliance with County Ordinance"No. 549 and a sj.�g stand'Regulations: ( { .. , JOB ADDRESSjLOCATlO .dC2j3-,--1,-�'-_' - - ----"--- --------- CENSUS TRACT __5:757------- Owner's Name , 1/_/"---- - -------------- r----- --- --------------------- ---------------------Phone SJ- i7-6 i /----- Address ----- A4-e----------------- -------------- --;---------------------------------- City ` � '`!� --------------------- - �/ p {. L License *X F,-23--6 Contractor's Name ------1tT�,�....--- - f12��/'------------------ ---------- T Phone d�``; Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court i❑ I Motel ❑Other --------------------- --------------------- Number of living units:.../---- Number of bedrooms "- '__-Garbage Grinder -----------. Lot Size 9Me 7,:e------------- Water Supply: Public System and name ---------------------------------- ------------------------------------------------- ------------•---------Private Character-of,soil to a depth of 3 feet: Sand'K Silt❑ Clay I❑ Peat Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material j 1f----- If yes,type __________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) W f NEW INSTALLATION: (No septic tank or seepage pit permitted lif public sewer is available within 200 feet,) )) s PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size--- ---- ------------------------------- ------- Liquid Depth ---------------------.---_ P Capacity -------------------- Type -------------------- terial------------------- - No. Compartments ------- ---------=---- ~, Distance to nearest: Well _ __ __________Foundatio _"__________________ Prop. Line __-________-:________ LEACHING LINE [ ] No. of Lines ------------------------ Lengtha of elch line------------- -------------- Total Length 'D' Box ------------ Type Filter Material _-___•--------.....Depth Filter Material ------------------------------------------ Distance to nearest: Well ---- ________ Foundation ________________________ Property Line ________-______-_------ SEEPAGE PIT [ ] Depth -------------------- Diameter - --------------I Number -------- ------------------ Rock Filled Yes ❑ No ,0 { Water Table Depth --------------- ----------------- ---- ------- ock Size -------------------------------- Distance to nearest: Well ____ _______ ____________ I-------- ___Fou ation --------------- ---- Prop. line ---------.-___________ REPAIR/ADDITION(Prev. Sanitation-Permit# ---"---- -- -------------------- ------ --- Date ------•---------""--------•.------} Septic Tank (Specify Requirements) ----------------- - ------------------------------------------------------------------------------------------- Disposal field (Specify Require encs) ------------ -- ---------- ---------------------------- ----------- ------------ --------------- - ----------------------- -. ---- --- ------ --moi f7'r� ------s --- `� ------ /fx/r (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 licen- sed agents 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 Work an's Compensation laws of California." Signed -- ---- '------ --------------------- -- Owner BY ----------J_ Title ----- ----- ----------------------------------------------------------- (If other than owner) FOR DEPARTMENTI USE ONLY / APPLICATION ACCEPTED BY ------_-- `------------------------------• -- DATE ---------- - - 7 7 BUILDINGPERMIT ISSUED --------------------------------------------------------------j--------- ---------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------ ------------------------------------------------------------------- ----------------------------------------------- --------------------------- - - ----- --------------- ------------------------- -------------- ---- ---------------- ---- - -- -- ---- -- ---- --- - D # / 7 Final Inspection -� a e � SAN JOAQUIN LOCAL HEALTH DISTRICT Cr a u 0 1_'AQ Doi. 9AA W�