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R OFFICE USE: FOR OFFICE USE: J APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} Permit No.. ...5-�.6. � ........... ................................... ........ ........................•........---- Date Issued....�-8-_-.2,"��--------��- This Permit Expires 1 Year From Date Issued {{�� Application is hereby made to the San Joaquin Local Healt it per ,'t st ant kst I the work herein described, This application is made in compliance with County Ordin e' nd existing Rules and Regulations: �0 } JOB ADDRESS/LOCATION ..... ...... .. . - ------------------------------------CENSUS TRACT.--------- Owner's Name.... . `�{ ------------------------------------------Phone........---------------------- Address...-- ire. ... City-__... -------- --------_------- ........Zip_--------_------ ----- --- G / /} Contractor's Name. G License -D-L J.... .Phone.f l'A/--lj'(*0_7...-- Installation will serve; Residence ❑ Apartment House ❑ Commercial Orailer Court ❑ Motel ❑ Other....... ..... -------------------- Number of living units:...... ----•.--Nu ��p9e C�cir Lot Size.._lV__Q..1� ..a�-- v.--•---- ---- ----- -- Water Supply: Public System and name-- ------------------------- -------- --------------------------------- ............. ------Private Character of soil to a depth of 3 feet: Sand [J Silt❑ Clay E] Peat C] Sand Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material.. .... ....If yes, type_.-.°------------------------- - (Plot plan, showing size of lot, locate 3n of system in relate vire s, buildings, etc. ust be placed on reverse side.) NEW INSTALLATION: (No septic ank or seepage pit perTv�attd I c sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK I Size ... .. . . 1-0 Liquid Depth. -------- Capacity../ -0..0--_-Type...-_- 4............Mate�rial__.. .No. Compartments....�--............. ._...._-� Distance to earest: Well-.--------- -.......Foundati n..... L - Prop. Line.............. ........ LEACHING LINE [ ] No. of Lines _ -79....................Length of each line...- -1 -- ------ Total Length ..1.....70........... 'D' Box....1 Type Filter Material..... Depth Filter M terial.- -------------------- Distance,to ill ell.....1-0_0..._._.Foundation-----.................._...Property Line-------------............ SEEPAGE PIT [ ) Depth--_ er....' . Number----------- --------...... Rock Filled Ye No ❑ WaterTable -------- --------------------- --------------Rock Size.----.- -------------------•------ -- Distance to ne _..--/_40.0-------._............Foundation_........................Prop• Line._.....__-----___ . . _.. REPAIR/ADDITION (Prev. Sanitation P .....Date-- ------------------------------------------- Septic Tank (Specify Requirements)..... .. .. ..--..-...._---------------- Disposal Field (Specify Require%ents) _ _ ..........___ --------------------------------------- ------ .......-- ---------- 0� - ....- .......................... ......... .....-.--........---------...-- r ------------------------------------------------------- _C1%-- (Draw existing and required addition on reverse side) I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and tegulations of the Sart Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of he w rk for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's (l n tion laws of California." Signed------. . -.----- Owner By....... ... --- �. Title . ------------------------ (If other than owner) FORDEPARTMENTUSE ONLY APPLICATION ACCEPTEDBY �� C� ------•....... ...........DATE ---- .. DIVISION OF LAND NUMBER_ ..... ..... .... . -.DATE......__......_.-----....-__ ................ ADDITIONAL COMMENTS--------------------- --------- .............. ....... ---------------- ----------.......__.....-_ ------•.... •------ ------------------------ --- - Final Inspection by------------------------ ` ------ ----•-------------...-- .......-.-.. --...Date.-- .1.. E" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M