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FOR OFFICE USE: S FOR OFFICE USE: !1� APPLICATION FOR SANITATION PERMIT p d Permit Na.. f/ i ------------------------------------------- -------------- - ---------- (CoWg ete`in Triplicate) ------------ -------------------------------------------- fr L i Date Issued -3__ 7/0-79 '�s_r. _� -:__< .: This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for 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: Y { - �� o ` � � s- -JOB ADDRESS/LOCATION--------- ----- -------`------------- - ---- ' C Owner'sName L77�—US 1 Name.--_. �'X63"�[ '_ ,><'' __..-._: > Phone-- -----------•------ } --- c--� Address_.-2313-9T--6---:5`- y� r ----- p ' --- -------- - `. City_..__.t. � P-_. _ _Zip Contractor's Name---- r1l +4'��.._{_ At�� -_g-PP_�___-_License # �7PhoneO._y_ _�f� _____ i Installation will serve: Residence ❑ Apartment House.❑ Commercial &4—i1-ailer Court ❑ Motel ❑ Other--- -- -------------------------------- --- Number of living units_________________Number of bedrooms___.____.__-Garbage Grinder___.___.___ - Lot Size.-- _L�' _.__ _ _______________._4_.._ W; 1 - Water Supply: Public System and name- -------- ----- --- - '--- ----------- ------------------__:-------------.---------------------------- ------------------Private ❑ 11 Character of soil to a depth of 3 feet: Sand K Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ �' Hard an-- Adobe Fill Material es e_________--------------------- (Plot ___. '_ - P 0 = ❑ f yes, type - -- ---- l (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 tankor seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ["] Size_ ___# �__10o___________________ ---,-----Liquid Dept Y_�_f____.___.__ - _ Ti ¢ Capacity--L --------Type-----------------------Mate;rial------------------7---.-No. Compartments-- -------------- -k Distance to nearest: Well_,, ��___________________________Foundation_-_W.-____________Prop. Line._____.______..__.___,._.. r LEACHING LINE [ ] No. of Lines.'1YQ90_______________Length of ea�hhji e..____ _.______._-__- Total Length..___ ___________., _r CC -D' Box__. .___-�T,pe Filter Materia�__!_/�___ pth Filter Mat/rias.____I _____---_--------------------------- 1 -Distance:to nearest: Well___®Q_' J----.Foundation----- _P________________Property Line-----------________________.__ SEEPAGE PIT [ ] Depth-----------------Diameter.______ __.._.__--Number___ti___________________________ Rock Filled Yes F] No E]Water Table Depth---------------- -------------=------------- -----------Rock Size--- ------------------------------= Distance to nearest: Well-------- ----------------------------------Foundation--- ----------------------Prop, Line--------------------------- REPAIR/ADDITION (Prev. Sanitation-Permit#---------------------------------------------------Date---------------------------------------------1 Septic Tank (Specify Requirements)------0------------------------------------------ ' Disposal Field(Specify Requirements)---- 1-------------- ;~ ------------------------------------------------------------------:--------------'------ -- ------ ----------- ---------------------------- --------- ---- --- -------------------------------- ------------------------------------------------ ----------- --- --------------- ----------------------------- r (Draw existing arid-required addition on reverse side) 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: ; .4 certify that in-.the pei'forrnance of'the work for which this permit is issued, I shall not employ any person in such manner�as to become subject Wo man's C mpen iop law of California." Signed - --- -- ------ -------- = " "' ` - Owner . By --- ----- -------- - - ---- Title -: " . (If other than owner) ' FORD ARTMENT USE ONLY I APPLICATION ACCEPTED BY!--------------- -------- --------------------- ---------------------- ------------------------------------DATE.---- - -ZW.7.7f---------- _ DIVISION OF LAND.NUMBER-------=------ -- ------------------------ - _DATE-- ----------------------------- ADDITIONAL ---------------- ------ADDITIONAL COMMENTS------------------------- ------ -----I---------------------=------------------------------- --------------------------------------- ------------------------------ a _______________------------------------------__------------___ _ ______________________-------------- ______,__________._______.__.______________.______ _-____._.________.____ Final Inspection-by:--:—.-- .__ -- -- ---------------------`___Date- l . EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT rsF&5 21577 REV. 7/7b 3M ` -