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cfr FOR OFFICE USE: OR OFFICE USE: . : APPLICATION FOR SANITATION PERMIT 1r+. . ............................. Permit No. Y.�Q.L!.... (Comphite in Triplicate) .................................................... .... I Date I ssued..b f 1.1. ..2.x1... dr 7�f: This Permit Expires 1 Year Ft-om Date Issued 'lei A�1` •,' Application is hereby made to the Son 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: G, // ;� o ��:• JOB ADDRESS/LOCA N.. 1..q,�.rJ.--3-........ �.....�f.Z..-(�....�.1C!1 ................................. .........CENSUS TRACT................................. yL„ Phone.............. ..w . Owners Name.. Address........... .... .... .. ..oZ�.of tel ... ..... 'u.... .. ... . . ..�"L...City......... l ' Phone............................. t Contractor s Name............ . xt�cd.. � nse .. r-"tHouse.......�o Licec al E] Trailer Court ❑ 1Apartment r++ Installation will serve: Residence❑ Motel ❑ Other... • ^" '•' Number of living units:................Number of bedrooms.............Garbage Grinder............Lot Size........................... -••.••••.""'•..-•• - Private' Water Supply: Public System and name.........:....... ................. . . ........................................... Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Cloy Peat❑. Sandy Loom❑ Clay Loom ❑ Hardpan❑ Adobe ElFill Material............If yes,type................................ 'r (Plot'plan, showing size of lot, location of system in relation'to wells,buildings,etcmust be placed on reverse side.) F i,.. �d NEW. INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,). 3; PACKAGETREATMEN7 [ J SEPTIC I J Size............................... ....... DeptFi�......__........_...:....t _' Capacity........... .. ......Type.......:....._........ Moterial........................:..No. Compartments..../.......... ..................� _ r. Distance to nearest: Weil :..............................Foundation.........----•-----..._.:.Prop. Line................... LEACHING Total Length.............................. No. of Lines................•--........ Length of etch line......... 9 r ,. RING LINE [ J - e ...........................:...' !t 'D' Box............Type Filter Material..... ............. Depth Filter Material................... Line................................. Distance to nearest:Well.............. ....... Foundation..................... .....Property ._.. Rock Filled Yes❑ No❑ x SEEPAGE PIT [ ] Depth... ............Diameter....................Number_............. ........... -• t L ............... �. Water Tabie Depth.........................................................Rock Size..... ...... ............. . . ; Distance to nearest: Well...........................................Foundation..........................ProP- Line......................... r " Y� r. ............................ ..Date................................_... REPAIR/ADDITION (Prey.Sanitation Permit#.................. y _...................................._... Septic Tank (Specify Requirements)...... ... .. ... �'........... �So.... .... �..�- - .... .......•-- -•----•-`�•........................•--... Disposal Field (Specify Requireme.�ts) ... - �d -� • i; .... ........... ........................ (brow existing and required addition on reverse side) �-•• I hereby certify that 1 have.prepared this applicntion and that the Hork will be done in accordance with San Joaquin County Stats Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents Ordinances, signature certifies the following: 4 "I certify that (n the performance of the work for which this permit is issued, I sl. A not employ any perron In such manner as to become subiect to Workman's Compensation laws of California." Owner s Signed.......... ....................... ............. i By............................... • (if other than owner) FOjk DEPA�MENT USE ONLY ... . . .. ....DATE . . .. ...................._..... APPLICATION ACCEPTED BY. .................. .... DATE............................... DIVISION OF LAND NUMBER. . - ..... . ............... ................ . ADDITIONAL COMMENTS .... ......... .. . ............. ........... Date ... .. . .. 13 Final Inspection by: Fss 41677 REV.7i76 aM EH 13 2A SAN JO N LOCAL HEALTH DISTRICT