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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Q ................ ........................... {. Permit No. ...76-.-7r, (Complete In Triplicate) .._. . This Permit Expires 1 Year From Date Issued Doti ls�ued ................... Application is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work herein described. This applicati n is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LCATI N . ki.e-WPO.RT................."----................... ....."..,.�........,..CENSUS TR CT ...... .................. Owner's Name . ............... A � ... Rl-TC 1Aji1 D----.................---......--........ :....:................Phone Id_1 ��... . _. Address . .. ... .._ TOCk�"o _ ... .....�.J.� .- .�..�.............. ...............................city . .1�..._......... ........1.�.�.................... .... Contractor's Name .......... r. , +9a�'L�J,S'.H. �P&S'.......................License ih &9-343.. Phone iW- 49Z40.7........ Installation will serve: Residence,"Apartment House fl Commercial OTraller Court 0 N1.` Mote! ❑Other.:..._... i Number of living units:..... ..... Number of bedrooms ......Garbage Grinder ............ Lot Size .............................................- Water Supply: Public System and name .---------••...................................................................................................Private Q Character of soil to a depth of 3 feet: Sand 0 Silt Q Clay ❑ Peat❑ Sandy Loam[] Clay Loam ❑ Hardpan❑ Adobe ❑ Fill Material ......... if yes,type......... ............. (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 se page pit permitted If public sewer is available within 200 feet,} r� PACKAGE TREATMENT j ] SEPTIC TANiG ze. rl... .......................... liquid Depth . r�.......... Capacity _t. ±. ..... Type �t� -. I. Material►J 'a(' T,-. Not Compartments ��II - Distance to nearest: Well JN-astic............ ....Found tion . ............. Prop. Line - . . ...._...._. LEACHING LINE � No. of Lines ... .................... Length of each-ii e..-_-- ... ........._._ Total Length ..... ©----........._.. 'D' Box ..... ...... Type Filter Material*�` Depth//Filter Material _5.......I........................... Distance to nearest, Well Kottff......... .. Foundation L.Q. ............ Property Line ........�7�.,�,�. SEEPAGE PIT f4 Depth .�..�.5r......_..I... Diameter Z_...... Number .......t................... Rock Filled Yes j No ❑ �L Er r Water Table Depth L7' �- Rock Size ._.....Z...--..... ...,....--- 41 Distance to nearest: Wel! JO.NC...............:........Foundation;lp........... Prop. Line ....46.............. REPAIR/ADDITION.(Prev. Sanitation Permit# ............................................ Date .................................. SepticTank (Specify Requirements) ...................-.....................................................................................••---...-.............................. Disposal Field (Specify Requirements) -----•-•................................ . . .............. ........................................7......................... ... ..r.............................................•--.._.............................. '--••...............................................-----------•------------------......-------.^..........__. ............................................................................................ (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done In accordance_Wflik•San jJ aquln County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.DlstrI&Hand 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 Workman's Compensation laws of California." Signed --- G -------••- --- - ----- ------- ------- By -- Title .._.tmA.T,P� (If other than owner) � • Li - .................................... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...- . __...__.......... ................... DATE ........... ,. . ..7 - ....... BUILDINGPERMIT ISSUED -------------- --------- - --••--•-•--....................._..---------------------.._. -................DATE _------ ............................... .. ADDITIONAL COMMENTS �.. ....... ... ..... = ------------------------------------- --- ��. � ::� _ --------- ..--- --*.......................... ---------------- Final Inspection by: ..... .....---•-- •--------- . ............................Date ---- - ---- .... EH 13 2 1-6 Rev. SAN IOAQUIN L HEALTH DISTRICT $f 7 3M