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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------- Permit NoX----q/y ----------- `----- (Complete in Triplicate) -- - --- Date Issue __7A;N. ;?f ----•------------- - --------------------------------..._-.-- This Pe�iitit E3cpirew 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: JOB ADDRESS/LOCATION---- -�.�- 69_q------- f�I----------- -U-5 1!-K)-----------ie-8--------------------CENSUS TRACT----------- -------------------- 8? ----------------- Owner's Name---- MF{�1 �:_ 21 L- ---------------- ------------------------- --------------------Phone---�� - --�/U-`---- ---Ci e S3.3.F---- Address-----------_..j�/'1�- -------------------------- - ------- tY----�.��'-�--C-''�---------------_ZiP------------ -- -------- Contractor's Name------ ----------------------------------------------------------License --------Phone-- 1 3 %Y------ Installation will serve: Residence [1 Apartment House.❑ Commercial ❑ Trailer Court, ❑ Motel ❑ Other----- ----- ---------------- Number of living units:-------L------Number of bedrooms_-._I------Garbage Grinder------------Lot Size-----/R ----------------------------------- Water ______________________________Water Supply: Public System and name---------------------- ------------------------------ ----------------------------------------------------- ---------------------Private [ 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 op reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,J yih � PACKAGE TREATMENT [ ] SEPTIC TANK [ j Size------1�_- -----_��_"___ r-______��_ ---------------Liquid Depth----__________-____--_____Oq ,q Capacity-- �-ZOO------Type-P!�-----Mate-rial__Cell f .T------No. Compartments------ 2---- ---- ---------------� I Distance to nearest: Well-------------- Line_-- 25---------------- LEACHING LINE [ ] No. of Lines-------__--------------------Length of each line---------- dotal LengthO -----------.___._______ 'D' Boz _____Type.F..ilter_Material, I I2 DP.pth Filter Mnter a1 .M1--------------------- -- -------- ---------- -- t n f u. 2� ; Distance to nearest: Well____ ___ __________Foundation__. --_---_ __-_ -Property Line.---------------------------------- SEEPAGE _______- ________-SEEPAGE PIT [ ] Depth- ____--_-_Diameter-___-----------------_ Numb,.er---- - _____________ Rock Filled Yes ❑ No ❑ Water Table Depth------------------------------ --------------------------Rock Size ------------ ----- ---- ------------- Distance to nearest: Well.------------------------------------------Foundation --___ ---------.Prop, Line__--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#_.._____________________.,___.._.._-----.-------Date-___-.--_--_,________ `:-__.-________-----_) Septic Tank (Specify Requirements)-------------------------- -- -- --.---- ------- ------- ------ Disposal Field (Specify Requirements)..-------------------- ------------------------------------------------ -------------------------------------------------------------- --------------------------- (Draw existing and required addition on reverse side)' I hereby certify that l--have-prepawd-dais-applketion 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 person in such manner as to become subject to Workman's Compensation laws of California." Signed----- --- --- -----------------------------------Owner By--- - -- --1 '"-�r.' f�. �F� Title_ (If other than owner) FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY____ ___ _ _ zS -- DATE - !--------------------- DIVISION - - -- -- -- -- ---------- DIVISION OF LAND NUMBER------------- ----_---- - ------DATE----------- -------- ADDITIONALCOMMENTS----------------------------------- ----------------------------------------------------------------------------------------- ------------- ---- -----------------------------------------------------------------------------------------• -------------------------------------------- --------------------------------------------------------------------- - --------------------------------------------- -------------------- ---------------------------------- - Final Inspection b ---- ----------------------------------------------------------------------- Date r ?> - � ----------------- c EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT: F&s 21677 REV. 7/76 3M