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f, FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------- ----- ------------ Permit No.4---�T- -- 53 y [Complete in Trip irate ------------------------- ----------- - --------------- r � i -74 Date Issued---b _---_- -. -------------- 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 install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: OB ADDRESS LOCATI /-2Q -.------ - �`-- -------- - ---------t-:--..CENSUS TRACT__-1r�" J '--- / Owner's Name... Phone---d6 � ' -------- Address - P`- =' '��aW------- -- ----------------- --City-- C�`� �': -- ----------------------ziP----------- ' Contractor's Name- __..9--- ---------'----License Phone Installation will serve: Residence ❑ Apartment House,❑ r Commercial ❑ Trailer Court ❑ Motel F1 Other---1t�u-------------------------- Number of living units:-----f--------Number of bedrooms__1------Garbage Grinder------------Lot Size . - - .--- Water Supply: Public System and name------------------------------ - -----------------------------------------------Private Q Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 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 seepage pit permitted if public sewer is available within 200 feet,) ` PACKAGE TREATMENT [ ] SEPTIC TANK [� Size--------- S �'�"��`---------------Liquid Depth. ---------- PACKAGE ---------------- - Ca acit jRk00 -T e___] "---------Material..__Cp4-------------No. Compartments..._Z_.___------------------ P Y YP r , — r Distance to nearest: Well--__ f p--------------------------Foundation-- 1_d-------------Prop. Line--- ------------------ 440 ' O , Len ------.Total Length -- -�------------ ----- - LEACHING LINE [�No. of Lines------- gth of each lin&------------------------- Y r ar 'D' Boxly- -Type Filter Materialf-!�— r�';<<Depth Filter Malenol-----------------r------------------ ----------------- Distante to nearest: Well-- .1 �---.--- -----Foundation___--1-3-----------------Property Line__ _-----------_- s - _rr SEEPAGE PIT �]' Depth_�S_-__--Diameter-.- _�. y / Rack Filled Yes No - .-Number------------ ' ❑ nn r, Water Table Depth----------7-p----------------------------------------.Rock Size---/-- ---------------------s--------------- r Distance to nearest: Well---- -------------------- -----Foundation------?25-r---------- Prop. Line0------------ ----- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------------------------------) Septic Tank (Specify Requirements)--------------------- ------ --'�------------------ Disposal Field (Specify Requirements)---------------------- -----------------------------------------W------------------------------------------------------ - ----------------------_. -------------- --------------------------------------------- ._ ---: -, 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 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, I shall not employ any persaon�in such manner as to become subject to Work an's Compensation laws of California." y Signed - Owner //�� x $ -Title----Cll.C�n u --�¢t�- y -- ---------- (If other than owner) FOR DEPARTMENT USE ONLY �`"�`� APPLICATION ACCEPTEDBY . ----- -- -------------------------- DATE---- '-- -f- ---- --- ------- -e --- DIVISION OF LAND NUMBER-------- ------------- ----- - DATE. ADDITIONALCOMMENTS--------------------------------- - ------------------------------------------------ -------------- ------------------- --- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- Inspection b ----------Date- -- Final Ins P Y:-------------- - - ----- -- - - --- - EN 13 24 SAN JOAQ LOCAL HEALTH DISTRICT Fas 2107 REV, 7/76 3M `"J