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Y FOR OFFICE''USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...... -- Permit No.� .� ............. ... ..... -• •-•�--• .. - -- �"" (Complete in Triplicate) ��-•�� - ......................-.......................... Date Is5ued.2 ._ ......................................................... 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.... ----....A"'?!......... ----------------- ..".CENSUS TRACT---------- ------------ ....... t Owner's Name.---....Mel X. P6.Z P_sd, J. ----- ..............................-. -...Phone _.�. � c9 ..r.--. r LA .........Cit S c Ta.�sy. ---------. _Zip---_---- ; Address...".'�.O..S$._.. .1.��../C�-��.1.. --..��.-"-------- ------�- � ��- � Y--- - - - - S4_ sLicense # �`71"3 y'G3. ....Phone..-. a..7 Contractor's Name..... ,.-iP�4_ /Sf,/.. ...-.................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other...... . ----------------------•- Number of living units:___:_ ---_.Number of bedrooms..".-3 Garbage Grinder--,------.--Lot Size."-....".-...... .. . . ............:.. Water Supply: Public System and name-- --------------------" ----------------- ------.".Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy,-Loam,[] Clay Loam ❑ Cy Hardpan ❑ Adobe I& 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.) 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size....... .................."... ......................Liquid Depth.-------------------------- CapactY.. ... ......... Type..." .........:..... ......Material.-------....- ------------ Compartments-------------------------------- - r Distance to nearest: Well-_._.-.""............ ...... .......:......Foundation.......... . ----}-.-- - Prop. Line....------- LEACHING LINE f 1 Na. of Lines - ------------------"------Length of each line:..".... ---------------i.-:_Total Length _.- --------------- ---...-------- 'D' Box.......- Type Filter Material.:..---.._: .:...Depth Filter Material--...-.....-......----------------_---....__-------------..- ` Distance to nearest: Well............... Foundation------- -.----Property Line.-`::'`.--.. ----- ---- ---- SEEPAGE PIT [ ] Depth................Diameter---------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth----------------------_- - - ---_ ------------- ---Rock'Size.---- - ------------------ Distance .. , Distance to nearest: Well-- ----- ---------------- -Foundation......---------. ,:.._.Prop.'Line...... ------------- REPAIR/ADDITION --------REPAIR ADDITION Prev. Sanitation Per.mi.t#............I........ Septic Tank {Specify Requirements)......... ..................................... �„ ---------� Disposal Field (Specify Requirements)... t, --------------- --------------------- . . ----- ---------- ............... -------- ------------------- ...... -.- ---------- --- -- -----. (Draw existing and required addition on reverse side) f (hereby certify that I have prepared this application and that the work will be done in accordance with .San Joaquin County i Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home'.owner or licensed agents signature certifies the following: ` x . "I certify that in the performance of the work for which this'p.ermit is issued,y1':shall-not employ ariy:person in•such manner as 4o become..su_ject to (. rkman's Compenscftt'an lows- of California." ` ] 0 .. . - ?� .- Owner Signed-=-.::. � _:,�. . :. -- - � ---_::�' ----- - BY _.. .. - - Title...... Acs. Of other th�owner) k Z . FOR EP TMENT 1: O ' APPLICATION ACCEPTED BY DATE .:- - 7 -�... ... ---- -- - . " ............ ..... DIVISION OF LAND NUMBER DATE.... - ADDITIONAL COMMENTS....." --...... f&. ,:. -,, ---- --------- ------ --------- - t ------------- ----------------------------"------ -------------- I _ ------ k� ....Date. �� "..��. ....__.... Fina! Inspection by:---.- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M