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1 ; FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7�3i7 Permit (Complete in Triplicate) No. ------------- ------------- -- Date Issued___- -------------- 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. 544 and existing Rules and Regulations: �JOS ADDRESS/LOCATION----- � .- ........------�E- j a ----- -- -�----------- - -------- = .CENSUS TRACT. Owner's Name.. iG '/. L_f�. '/ � Phone.--r--- ' € - ----- ---- - I /�' �'-�-fid- Address ----- ------- j - --Ci j 1 --�/v Zip �. S� �G6--F 6Phone- Contractor ` - s Name--, ��-�ll��'/.---- - --- - ------�'------ -----------License #--.-----� ---------� Installation will serve: -.Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court. ❑ t_ Motel ❑ Other-- Number of living units:------._____---Number of bedrooms^--____.---Garbage Grinder----------.--Lot Size_--- � � -- ----------------- . Water Supply: Public System and name T-------- - ---- ----=----- -._._---.-:- :-:-_ Private _... . . e Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ . Peat ❑ Sandy Loam ® Clay Loam ❑ } "Hardpan 0 Adobe ❑ I Fill Materia L..---------If yes, type-------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1 NEW INSTALLATION: (No 'se'�tic tank'or seepage pit.perm itted'if public sewer is available within 200 feet,) PACKAGE`TREATMENT [ ]` SEPTIC TANK [ ] Siz6-------------------=------ --------------------------Liquid Depth.--------------------- : - Capacity---- --- --------==Type--- ------='----------Material No. Compartments-- ~ Distance to nearest: Well--- ---------- ------------- ...Foundation---------------- ----- ---Prop. Line---------------=----------- LEACHING LINE :[ ] No: of Lines---- -------- •- -----Length of each line.-------- :---------------- :Total Length.-----.-----------------------_--- ------ i 'D' Box----_----- Type Filter Material---------------------Depth Filter Material -:------------------- -------- ------------------------------- Distance,to nearest: Well_;�-----------------------Foundation----------:-------------- --Property Line----------------------------------- si M ..-. IKI SEEPAGE PIT [ ] Depth.--------------- Aiameter-. -----------Number-------------------------------- Rock Filled Yes.❑ No ❑ --- -- ..- rel- Water Table Depth s'" = -------------------Rock Size. Distance to nearest: Well ----- Foundation----- --- --------------.Prop. Line-----------------------;--- i REPAIR/ADDITION (Prev. Sanitation Permit#---------------- ----- --------------------------Date.--_-_-.---______--.-------------------------} ' ---------- Septic Tank (Specify Requirements)--=------[ - --------- /-Y174_Ak - - - , — -1- � w----- l -------------------- 'Disposal Field (Specify Requirements)- l 9 ` �----- ------ --------------------------------- A., °----Re � , T / ' ------- ----------- -------------------------- CT ----- -------------------------------------------- ------ ----------------- (Draw existingand'required 1 addition on reverse side) ' t 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: r "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.Worrkman's Compensation laws .of California." { Signed W4_4 �ZTX7 of � say Owner BY- -- --- -- ------------Title------------------- - ------------------ -------------------" i weer) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------- DATE'--- ---- DIVISION OF LAND NUMBER._.__.---- ------------DATE_---------- --------------------------------- -- ADDITIONAL COMMENTS------ ---- --- ------------- ---------- - ----------"----------------------------- ------------------------ ------------=------------------- ---------------------------------- -- --------------------------------------- --------------- !J Final Inspection by - - - - --------------------------------------------Date EH 13 24 SAN JOAQ ✓ = UIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3m ` .(7.