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FOR OFFICE USE: .. FOR OFFICE USE i -� APPLICATION FOR SANITATION PERMIT FOR ------••-•--- -------- Permit No 7�` ----'� 9 1y ,l, �. (Complete in Triplicate) Date issued-� ........................... This Permit Expires 1 Year From Date Issued Application is hereby made to-the Son 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: t AM�Q ,} L L JOB ADDRESS/LOCATION....gQ`6-.1 wrT-�t�-�N{/...y--�-- ---------------�- ck4 - . -----.CENSUS TRACCTT----------------- .... ..... .. a Owner's Name / ----. . 'C-�l?'1 .�i�/.............. - ...... --------.... ---------- ------- ------- Phone /.F. �.'-`� . 'I OG Address....... .......��'/}"7?z.E---.. --------- .......Ci �-----�._ �! Zip-------- tY .. . ........... Contractor's Name------7;q, �/P/,<A_.Y, d ...... .... ........ License #. _P15orie. Installation will serve: Residence [L?o Apartment House ❑ Commercial ❑ TrailerCou Z ' Motel ❑ ....__ / 1 ... g X -Garbage . - --._- Water Supply: Public System and name - ----------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom,E] Clay Loam ❑ Hardpan Adobe [B1"' Fill Material.. .... -...If yes, type------------- ---------------- 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 seepagepit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( } SEPTIC TANK I } Size----------- ----------------/--------------------. ----Liquid Depth..----------- ------------- Capacity.... -----Capacity.... ---- Type---------------- ------Material ------ /--------- ----No. Compartments- ---------------- - - ------ ---- -- Distance to nearest. Well----------------- ---- --- ----...-__--.:Foundation------- - . .......Prop. Line .--..-.-.......--------- LEACHING LINE ( } No. of Lines .-------/.....------ . Length of eat line-.. . . . 1g - -,Len - - -- - =-- ---Total Length ....�f..�. .---..----- ---�--- --•-- 2�,, 'D' Box_.,......Type Filter Materiflt(O. + pth ilter Material—f-I------------- -------- ...... to nearest: Well--Mi----------------.I oundation--- ----------........Property Line.../?---------------....... . E } Depth_ _Diamete . Number__...----- Na SEEPAGE PIT ❑ �`�.. ..... -f �- •--•----- --- Rock Filled Yes f r it Water Table Depth...... �� f ----....... .......:..Rock Size./..(� z...�t. G Gy( R Distance to nearest: Well. s -------------- -------Foundation.. -....... --....Prop. Line.--,Z0. -• e � REPAIR/ADDITION (Prev, Sanitation Per #....---`--------- ------ - -----•Date-------------...................------- - ' x �... ' Q. Y. Q Septic Tank (Specify Requirements)-- 1I ..... Disposal Field {specify Requirements) Q=.F�1 � �G�/N .. .. (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 agents signature certifies the following: A/ "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 Workman's Compensation laws of California." Signe .Owner 4 / By /LGZ!.fr ------------------- -- Title... .... .. ---------------- ....... (If other than owner) fOR D§VARTMENT USE ONLY y APPLICATION ACCEPTED BY... ...--- ...--- -DATE . .. !Q DIVISION OF LAND NUMBER.------ DATE.. ADDITIONAL COMMENTS --- --- ------------- ---------- ".._..... ::.... �&- �... .............. ......... --------- - -----------"------ " _ G -- --------------- ------ --- V i Final Inspection by --------------- ------------ ------ --•------- -- ------ •--•----------------- ------- Date... _ ... EH 19 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M