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i FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMITPermit No..�} _ . d r} ------------------------------ ...... -•---- s (Com F, plete in'Triplicates ---------------------------- --------------------------- '"--.. - Date issued. .................... ...-•----...... This Permit Expires 1 Year'From Date7ssved 1� Application is hereby made to.the Son 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...:....r. Z. :.-FtZ>kSQ��----- f..�1C-_-•-- ------ CENSUS TRACT.. r S y �� tZC"f~�A!N - ;... one--- � ..... Pn 3 l Owner's Name..- -- 5...--- - •--••- •---� � ---------- Address..----- .... _...Cit (ZAC -------- Contractor's ---- ZIP �� ... Contractor's Name ----C.!�R�rI� ------------- ----------- ----•- -- .........-.License #--- y- !`f ... .Phone._._-t, [ Installation will serve: Residence y Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--. Grinder._-..:----:.Lot Sie-------------!.._...._. ------ z ------------ -------- ,2 I Number of living units:------- .......Number of bedrooms..". AC 3-__..Garbage Water Supply: Public System and name__ ----_._....._ ........Private Character of soil to a depth of 3 feet: Sand [5 Silt ❑ Clay ❑ i Peat ❑ Sandy Loam E] Clay Loam ElHardpan E] Adobe°❑ Fill Material.. ._.. If yes, type-.- 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 pit permitted if public sewer is available within 200 feet,) - i uid De th. .l1- _ r y ---- PACKAGE TREATMENT SEPTIC TANK Size ___ ----- 12 00 . Recp1��' C�ine�' Ca acit T e-- • ........_.Material - .Na. Compartments10 T P Y--- ...... Yp P-....� tvi a � -5 1 Distance to nearest. Well---_--- -----.- - --- Foundation.. Prop. Line---I---------- ----------v, LEACHING LINE [ ] No. of Lines ...... -...•------------Length of each line_:-.7d ------' '- -� -Total.Length`. -�. .._...... t t� !-: ca► ` 'D' Box---- Type Filter Material-...' Depth'Filter Material - ........... r Dist e to nearestWell----.-- Ch .------- - Foundation----11-0i-•-------- r�Property Line.---• SEEPAGE --------- PIT [ ] Depth `-.-��^ Diarrleta`r:. "-�`"`:�.-: � �==-'= ------ - =------=-' - - •.- - .- R'ock,Fili ed Yes ❑ Na ❑` Number. -. . Water Table Depth.-------- ----------------- Rock Size...... ........ ----- +- .-- Distance to nearest: Well .......Foundation-- Prop. Line... ..:_...... REPAIR/ADDITION (Prev. Sanitation.Permit#-----------•-------------•------- . .,__....-." --.Date-------•---•---------...-- ] f Septic Tank (Specify Requirements)...._-._..... - .......... .................. Disposal Field (Specify Requirements). -- -------------- -------- ------------ --- -- ----- ------ II. ` (Draw existing and required addition on reverse side) t i I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws," and Rulbs and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: i "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 Workman's Compe sation laws of California." � Signed... -. ..- ------ Owner 9 5.._.. ----------------- -------- ---- By.. f^"t- ------------ ---------. .-"..----- Title..__...--- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ......... -...DATE ... .:/..i `..1 -----.............. DIVISION OF LAND NUMBER.--_--....._ ---- ----------- ------------- .................... - + ADDITIONAL COMMENTS_-_---------- --- ------••---- ------- ------------------ ---------- ------- ------------••-• ................. .... ..... .. .. - " . _ __Final-Insp.d6on by:..�. ------------ ----------- ----------- ------ ...._.:. .. . D ato. --------- Fossr... WEH 13 24 �'`� SAN JOAQUIN LOCAL HEALTH DISTRICT 67 �1 76