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FOR OFFICE USE: YY FOR OFFICE USE: .PPLICATION FOR SANITATION PERMIT ................... ............ fCompleta in Triplicate) Permit No...71�' 7. ----��--•- - ...................... ...........I...................... Date Issued.!-3/779 ._.•...........................::........................ 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 //c/ompplQliance with County Ordinance No. 549.and existing Rules and Regulations: JOB ADDRESS/LO`CATyJO]415. .� /I}n1T .. .1- - ./�y}� CENSUS TRACT.........__.................. Owner's Name..Y;:.-L..Q. .....T�..................... -- ............................ ..........--............ ............. -----._....Phone-.�c�s..�.9 .`........... Address.. ry 1 f 1 T .�t. ' .................. Zi 9 .7.C....... + 62..7.._:w t.:.a.,...._�..j..-...." ............................._...._city.... yy p G Co/�a or'S_N m ..✓..)..!./..! . ..C!C.C.in-A ) '.,s - License .��t.7 .9.J3.......Phonelk.! ... ...........� n'f /7'Jg �.wN:s L �f . ix. r Qir(�CbA . ...: � - 9 I s al ation will serve: Resi encu:' Apartment ouse❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other..............................---.c............ Number of living units:.....1........Aumber of bedrooms.-.-3.....Garbage Grinder............Lot Size..�/..---A......... ......................... ..... Water Supply: Public System and'name.................. ......... '... -----.........----................_....._.................................. .._.. Private El 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 's available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ] Size..-�o�Ll9�.. .... ...... ...Liquid Depth ....................... � Capacity,00 ... ...Type. - ...............MaterialCompartments.._..47 ..................... pie t 0 r /�r Distance to neare•syt: Well......./. ---------------------_....Foundation...../..-,..-_.........Prop. L�inye..d.7. ............. LEACHING LINE [ ] No. of Lines........3........_........Length of each line..:../.( ...-Total s Length ... Z.(.Q........................ r D' Box... .......Type Filter Material{h.1�0.4'��..Depih"Filter Material...��........:.............................................. s - e Distance to nearest: Well....../P0.............Foundation:,,a�..---..........Property•Line....so...............;.......} SEEPAGE PIT [ ] Depth............:..Diameter..-------;..........Number................................ Rock Filled Yes ❑ No E3.;- WaterTable Depth._.c.........................----------------7........Rock Size...................-........................... S. Distance to nearest: Weil..............................._..._.....Foundation..........,...............Prop. Line.......................... REPAIR/ADDITION (Prev. Sanitation Permit#.....:..................... ....... Date---------..................................... 1 SepticTank (Specify Requirements).........:................-.............,.:-......... -------------+---------------------------------------------'......................................... Disposal Field (Specify Requirement;)...................... :}....................... ......------ -- ....... ......... . .------- -- -----... --................................ ...." ..........................................:.................................'...i..........................-....-----------------------..--------....,.........,........................................ ....................................................._................................_.-------- ...... _:........---...........-----................. -----......................................... (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, 1 shall not employ any person in such manner as to becom oub'ectttt7oWorkman's Compensation haws of California.". Signed.. rrwJ.............Owner By..................... ......... . ...................: ................ :................Title.... :. .......... . .....-----......_......................-- (If other than owner) FOR DEPARTMENT USE ONLY y APPLICATION ACCEPTED BY: ..........: ........ .....DATE .... ..�2�.-.7J-................. DIVISIONOF LAND NUMBER....:::...:.........."..................................................................... ...........DATE................................................ ADDITIONALCOMMENTS..................... ......... . .............;............................................................................................................ . ......... a ...................:--------.-----._............---........-.,........^.-.......................................................... -.................................. . .............. ......._.. ........................... - Final Inspection by.:............ ..... ............ .. ....--- .......-..................................... .....Date -----.. _.`" -J.. . EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6s 2216677 REV. 7n6 3M (44