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' �J .- FOR OFFICE USE: FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. r__7 _ _ Date Issued__r?-a_767:?g _________________________________________________________ This Permit Expires 1 Year From Date Issued a Application is hereby made to the San 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: JOB ADDRESS/LOCATION------------ /1"141e 1 --- ---- -4-`/------- \-�-' -._CENSUS TRACT-------------------- _-----Phone--- Owner's Name -------- #?D_ -------------------------- -------------------- . �Address--- ---------------------------------- ------------------------------------ Zip -------- -----------fe_a-- ----- r CosnensePhone------------- --- ,L Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El ' Motel ❑ Other---------==-------= ----- --------= :a ! ____Garba a Grinder __ Number of living units:.!-/ _Number of bedrooms_-�_ g �_. Water Supply: Public System and name-----'G,-Gr/ �-------.- ------ ----.:-----.- # �� La�� ✓f. F----=-----------------------Private ' I Character of soil to a depth of 3 feet: Sand E] Silt E] C1ay ElPeat❑ Sa y a X Clay Loam ❑ j Hardpon ❑ Adobe ❑ Fill Material------------If yes, type_--_-__________________ _____ l f r (Piot plan, showing size of lot, location of system in relation to"wells, buildings, etc, must-be placed ons reverse side.) NEW INSTALLATION: ,(No septic tank or seepage pit permitted if'.pul3lic'sewer is available within!200 feet,) � �-- 1 PACKAGE TREATMENT a ac tPTIC TANK ['T e______________Size Mate] ial------------------------- CNo. C .x Liquid Depth.______z_____________-____ i ; ------------------- j 4 p Y - ----- Yl' l ompartments________________ f Distance to nearest: Well---------------------------------------.__===:Foundation--------------------------Prop. Line----------------------------:4LEACHING LINE [ ] t ' i a. of Lines--------------------•-------.Len.gth of each Iina----_---- -----:----:-------.Total Length.)----------------------------------- D' Sox------------Type Filter Material-------------------Depth Filter Matercal___ - '------- . -°----------------------____- •. - Distance to nearest: Well------------------------------Foundation---------?_'_ _- _Property Line--___________________r SEEPAGE PIT [ ] Depth----------------Diameter-_-____:_________.Number---------------------------_ �' SrRock Filled Yes . t= 'y ., Y Water Table Depth - ------- ----------------------------------=------ --- Rock Size-- ----------- --------- Distance to nearest: Well--- -_ -___ _Foundation__A __ Prop. Line-------------- 1-71-1 REPAIR/ADDITION (Prev, Sanitation Permit# ___._ --_ ___ _ .Date ------- -"r______ ] I _ y `tea. ..---------------- I 1 F' l-. i � �i ..t �\ .--------------------------- Yyy« '� T !�"ti ! t Septic Tank {Specify Requirements) ��' - ------------ Disposal Field (Specify Requirements)------_--© 1 � / 4Y 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 accordanceitSan Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District:Mo:ne owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is'issued, I shall i of emplojp;any person in such manner as to become subjectjcf 's ompensation laws of California."' f Signed_'_ 5 __` ---- ------------ -- ------------Owner BY --- ------------------------------------------ = = ----Title--- ------ ------------------- (If other than owner) »<k FOR DEPARTl41EINIT"LISE;'ONL'Y— APPLICATION ACCEPTED BY------- ------ --- _ ATE. _ /7--.7 DIVISION OF LAND NUABER_-..--= ----------- ="r DAT ------------------; ADDITIONAL COMMENTS-------------- -------------------------------- ------------------•------------------------------------------------------------ -------- ------- ----------- -------- ------------------------------- ------------------------------------- -------------- --------------- -----=---------------------------------- ---- - Fina! "fns ection b �- - Date.__Sr�--___ _ ! _______-__ P Y• _ EH 13 24 SAN JOAQ IN LOCAL HEALT..,':DISTRICT F&S 21677REV. 7/763M 1