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FOR OFFICE USE: r( FOR OFFICE USE: lPPLICATION FOR SANITATION PERMIT `,( (Complete in Triplicate) Permit No;7e_,?6,3.. - - ------ -------------- Date ---.____.----__- 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: 20& 01 d JOB ADDRESS/LOCATION __-..pp/04".-._. - OAC .44e --- 5{.---- sCENSUS TRACT--------------_--------....... Owner's Name 4,p.._S2�O'-t.(:-- __Q - -- ----- • ----------------�p�-.---,--n-.y �pP,h�.o..ne..?X/�es,�..7_i1Y-_1_,a Address.- . -------- �'-( - -s-c ------------------- - -_Cltyvf�lM1#..Z&;e �ZlC' _Z1 ---------------------------- O P Contractor's Name-----------L..._ ... -.---_ --- ---s ---------------------License 4-L� .Y_3.---Phone._3X6� -_.YI-&7.. Installation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other..___ p _ - a _ Number of living units:....._.....__-Number of bedrooms.__-___.Garbage Grinder_ ---_----Lot Size......----Y J_...-....._.____._... Water Supply: Public System and name---------------------------------------------------------------------- -----------------Private X Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe"X 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,) �� O PACKAGE TREATMENT [ ] SEPTIC TANK [�Q � 'ze.._ X... ._ __'.__._------------------Liquid Depth. ------------ --/" .O Capacity..� �._....Type- "`c�------Malarial--`^ W ----No. Compartments--------- rZ-------------- Distance to nearest: Well__---/_�..._'f..._..___.__.-_.._Foundation..._____._..._...Prop. Line..d.____....._____.. LEACHING LINE No. of Lines_....__..---..- .Length of each line_---Cy.S_r----__ -------Total Length ---------- �` �� sy 'D' Box._._V.Type Filter Material:. FQp- ...t�Depth Filter Material_____ g...._--------._-------------Z_.._..._-_.__.... Distance to nearest: Wei l-----f60_�__-Foundation__�Q..."f.....__Property Line-_._�.__._-._.............. SEEPAGE PIT [ Depth...44* .-Diameter ._Number.............._2 ___ Rock Filled Yes No o 3 it Water Table Depth---------------------- --------------------------------Rock Size--- �- k - - --------------- � Distance to nedresY: Wel(,.__Lt4G._'t"-------------------Foundation_ _l.@__+'.__..Prop. Line... ...._....__-_._.... REPAIR/ADDITION (Prev. Sanitation Permit#....................._._� .__.__._.....Datio ) �} --------- ---.---------- Septic Tank (Specify Requirements)- - -------- ..._ -- ------------- -----^p - Disposal Field (Specify Requirements)---------- -- ------- ----- --------- ---�---- --- - --------- --- - -- - -- - --- --- --- - - - -- (Draw existing and required addition on re rse side) 1 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: "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---- --A '�/ Title . - - - ...- Cher than owner) D ARTM T USE LY APPLICATION ACCEPTED BY-------- - ---------------------------DATE. L- - - DIVISION OF LAND NUMBER.-- -- --- ----------------------- DATE - ---------- ADDITIONAL -------- - - -- - - ADDITIONAL COMMENTS.._....--------- -------------- -----/-----------------_ ----------- --------------- ------- ----------- ---------- - - ---------SL7 1r38._- - -- l Inspection -- do ----------- ---------- -- - -- ----- Final - - Flnal Inspection by:--------------------------------- - -- - - -- -- - -- -- ----- - - - - Date------ - - - - ------- EN — EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F63 21677 REV. 7/76 3M