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FOR OFFICE USE. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT. •----- .. - -- .......... ... .._ (Complete in Triplicate) Permit Na.Z�_�n4�-�-'�.- ............- .A� ......, - - Date lssued.7.f..�.7,9 ......................................................... 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.instail the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO .. . .r .3.77 ... i�lE+�a t �`' ............................CENSUS TRACT----.....---------.......... Owner's Name.......... ./��. - l� !�.!". .�+... L1.�. .... .�... Phone_...----- Q- Cit .Zi Address-- --- � - -�"-• -- - Contractor's Name....... ......... C� a,, License # -.Phone. .................. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------- Number of living units;...--- .......Number of bedrooms-..--_-...Garbage Grinder............Lot Size...J��... -.- - Water Supply: Public System and name------------------- --=---- ........ ......................._ .......!........... Private 5 Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam Rt Clay Loom ❑ Hardpan ❑ Adobe ❑ Y type ------------- �. _Fill Material..,�_.. ....If es, t e................ . (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',pi't permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ j SEPTIC TANK [ ] Size - ------------------------------•-.------------------------Liquid Depth--------.--.----:-.......... Capacity. -- ..,... ------.Type.......................Material ------------------ .,.No, Compartments.......................... -----� Distance to nearest: Well---- .....................Foundation..___.. ............Prop. Line------------------------o LEACHING LINE A No. of Lines ----------- :- .......Length of acIn Ii e._.____.. C)-�....- -.---Total Length ---------- .................... 'D' Box_ F�....Type Filter Material, s epth Filter Material._....... �.......................... .. t , .. �= to .._Distance.to-nearest: Well-_:.. 1.-----------Foundation....-.�1Q............Property Line_.._.��. - --............. ` i ----- Rock Filled Yes No SEEPAGE PIT { ] Depth.......... .....Diameter-----------------.-.Number..-.-------.---------__-..- ❑ ❑ tWater Table Depth----------------- ------------ ............ .........!.Rock Size.--...---....--"---------------------------.-.. I Distance to nearest: Well-------------------- -----------`:_.=Foundation-----................-----Prop. Line REPAIR/ADDITION'[Prev. Sanitation Permit#...._-...-----•--:------------------------ ----------Date---------__._.-.- _-_.....-........-------) Septic Tank (Specify Requirements)_........ -• . ....... -------=--- -- ------- Disposal Field (Specify Requirements)"----- --> r"-- __ �� --- - ----------- --....-----/-........ .... ............. Draw e tstin 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: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed---- za_IC41 ,.�- ;------------------- --Owner BY---------- ---.- - - - ---Tit.le ----------------------------------------------- ----------------- (if -- -- - (If other than owner) F DEP T ENT USE ONLY q APPLICATION ACCEPTED BY---- .. .. DATE .... Cl ......... DIVISION OF LAND NUMBER__ - DATE. ADDITIONALCOMMENTS- ............. -------------------- ----------------------- --------- ------ --..... - ......----- . -------------------------------------- -------- -•-•-------------- -------- -------- -------------------------------------------- - ---- -- --- - - . Final Inspecfion b Date. - , eH 13 24 SAN JOAQU.IN LOCAL HEALTH DISTRICT F&s 216 WV 7/76 Sea