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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.� = Er . 1 (Complete in Triplicate) ; •- ........... Date Issued..,3-f3.^� ......................................................... This Permit Expires I 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`compfiance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION MA_ftT-EU Ave - - •----------- - � .CENSUSTRACT..:.------------- ---------- � Owner's Name,-MO..G�. '..�.I ,RTH� 1�,.1 ..'f`.1.(.�0. �_--------------------------- Phone s.= .a� Address.:_ ' _. s.... -AN---1---- AT.E.Q_ ------------- ---- ......... City �T.IQ bC ?.�1 Zip Jho Contractor's Name.......... - ------------- - ------------:... - . _.License # •-----. ------- - --- -Phone.......=-------------- Installation will serve: - Residence Apartment House E] Commercial ❑ Trailer Court ❑ �»- j`� Motel ❑ Other........ -------------------------- Number of living units: ...............Number of bedrooms._,'3.....Garbage Grinder.............Lot Size---65 w�.Q.............-............ Water Supply: Public System and name__...s....................................... ----------•------------------••-- .......... ..------..-------- ------..Private ❑ . Character of.soii to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ : Adobe Fill Material.. .........lf 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 saver is available within 200 feet,) PACKAGE TREATMENT ' - � T� A [ ] SEPTIC TANK [ ] . ;- Size...... - ----------------------------------------- Liquid Depth._..-------------...{.----- Capacity-------------------- Type..-----...-----........Material----= ..... .........No. Compartments------"--------------- `.r.�....- t Distance to nearest: Well-------------------- - ....Foundation-----. ............Prop. Line.................------.---.%,A LEACHING ONE [ ] No.'of Lines---------------.-----------..Length of each line --------'.------------ ---Total Length --- -----_------- 'D' Box—.,......... Filter Material...--... - Depth Filter Material................................................................ ". A Distance•.to nearest: Well--------------------------- Foury a, n.F_- -�`� :.,._P, p rty Li_ nye---:...................---......... SEEPAGE PIT [ ] Depth - - .---.-: --Diameter----------------=---Number--.------------- ----- Rock Filled Yes ❑ No ❑ Water Table Depth-------------------- ----------------- ----•- ---.Rock Size--.-........... . ----------- {-..----- - Distance to nearest: Well ........:..................................Foundation.----- ......Prop...- p. Line..-.- ------- ..-- REPAIRADDITION jPre,. Sanitation Permit#....._._................ --------------Date-------------------.......------------- ------) ; Septic Tan cify Requirements)------ ----- ------ _ ...=------. ---:-----.+...--- Disposal Field Specify Req ire A;s1l ....-, - - - --------- --------- ----------- I (Draw existing and required addition on re I hereby certify that I have prepared this 'application and that the work will bedone side( 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. f Signed...46 1Tr. ------ - ------------------------------......Owner By............................................. _:., ,- wTit]e,: -�.�...---;,�----- ...------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. ----.-..DATE ----.�J��a-'". .�--------------- - -- v�"` ... DIVISION OF LAND NUMBER . ...... -... ---- --------------- DATE.... ADDITIONAL COMMENTS...----... �--- --- . •------ ----------------- ------- - Final•Inspection by:... .................Dote-------`. . i EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M