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w 1. FOR OFFICE USE: Z--Q 7- .>Y.2 ,7 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------- ------- -- (Complete in Triplicate) Permit No..__�-_--_ ,3�3 ; --------------------------------------------------------- 5 �� 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, 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION_. �2 �r4_.�..��A_owp� ------------------------- ----- ----------.CENSUS TRACT-------------------------------- Owner's Name- ---------- ------Phone-- -------------------------------- Address------I�i°�.. `-'--- City4rC -----------Zip----------------- -------- E Contractor's ...�'4ll 1C rP__. �_:lti�,-----License -Z----Phone.464r:7n ark' !axil. Installation will serve: Residence ® Apartment House.❑ . Commercial ❑ Trailer Court ❑ Motel ❑ Other--- ----------- R ------------ r------- Number of living units:------- -------Number of.bedrooms___ -.__-Garbage Grinder____'__:____Lot;-Size_,��X/-3L,�C_3y.'�._f�_�_tk_��4�-______ } t. , 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 k 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 b4 Size_____�1-� _.____ 4�4 ^ _________ ____Liquid t Depth----474r------_____ Co. Compartments------------------------------_-- apacity- /Ad! ` _ -Mat t Distance to nearest: Well.----_1_d_p------------------------------Foundation:, __._____.Prop. Line-----f'O-_--_-___- -_ -- # LEACHING LINE No. of Lines- .----._ a Total:Length._.._X7_0__'________________________ �. _____.____.__.Length of each line._____.__. y 'D' Box.____X_._Type Filter Material_. 0G{ ..Depth Filter Material-----1- --r-__.___` __-_----------------- 1:1 Distance to nearest: WeIL___. 40 '-_------.Foundation---_._-�--3- .-----_-.Property Line-__.__f__G__�_.--_-----___SEEPAGE-PIT [ ] De th-----=----- ----Diameter_.____.__-_.__ _._Number_____---- -------____ _----- Rock Filled Yes ❑ No Water Table}Depth----------------- ------=------=-------------- ,---- -Rock Size.------_--------- -Distance,to nearest: Well______ _ �.__..._______________ ':Foundation___..__�."._T________ Prop, Line._--=f =REPAIR/ADDITION (Prev.-Sanitation Permit#---------------------- --------_--"r:-_-*µ_'rtDate_.--r.___ .- _--__- ___._f_._Septic Tank (Specify Requirements),,_.lZ�G!.- --�'"-�-LG�•--------------------------------=---•---- - ---------------------------------------------- ------- Disposal Field (specify Requirements), 3:-"-.:`a= Z 41 X3------V_45_7"Fi Gt' ' - ------ ----------------------- ----- --------------------- ---- _. ----------------------------------- #, (Draw existing and required addition on reverse side) 1 hereby.certify that have prepared this application and that the work will be' done in accordance with Son 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 be ubject to Work mpensation laws of California." i Sig - -- C ----------- - --- ------Owner BY ----- ...... Title t --- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____ - - - - ------------ -- --- - DATE. DIVISION OF LAND NUMBER------ --------- -- -- ---------------- --�-------.DATE.-------�--�----�----r----�----� ---�-----�---� -- ADDITIONAL COMMENTS------------------- ------ - . - - - ' ------------------ - . - ----------------------------------------^----------------------- ------------------------------- ------ r ------ ----.---- - - Final Inspection bye-- --- - (- - -=--------ru_ ------Date--- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M