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301 o �G(S Sm-.. ��- �l�-� � 7 FOR OFFICE USE: FOR OFFICE USE: APPWCATION FOR SANITATION PERMIT ------------------------------- ---------------------- (Complete in Triplicate) Permit -------------------------------------------------------- k-0!-1 T c�vt�f 2(( _T Date Issued _ �______ -----------------____-------______----------------------- 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: GLv [. JOB ADDRESS/LOCATION----- ---K--- ----------��/s��-r-.----5.yN_-�------»�---/�el/Py CENSUS TRACT-------------------------------- L e /' --- TomJq----- -----------Phone-------------------------------------- ----- Owner's Name---------- ce - --- - -- - --- - Address--- 30,_P00 ---- ------kd------------------------------------City__77*--4.C_1V Zip ------ Contractor's Name...__ �_ _(tlT.�,�1 �Y_ . _SOIIo' E----------- ✓`�� 9--------- - -- ---- -----------------------------_License # ��---- -------Phone------------ - Installation will serve: Residence[g Apartment House.❑ Commercial ❑ Trailer Court ❑ �, Motel ❑ Other-------------------------------- ------------- v Number of living units:------- .__----Number of bedrooms__1_____Garbage Grinder------------Lot Size-----------------------------------------------.------------ Water ___-__ _Water Supply: Public System and name--------------------------------------------------.------------------------------------------------------------------------------Private 1 Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ® Hardpan ❑ Adobe ❑ Fill Material------------If yes,type_____________________.__-__ !v (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Z NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) __4 PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size______________________________________________________Liquid Depth._______________._.__. Capacity-1-20 d------Type- eoo"TMaterial-----CO IVC--`-----No. Compartments-----7-t-------------------------`j Distance to nearest: Well.------------------------------------------Foundation-------/ -------------Prop. Line___ �___.________ LEACHING LINE [ ] No. of Lines__A°_�X..7�.�-__Length of each line...__________________________.Total length.__________________________-____`--- 'D' Box---1------Type Filter Material -____-Depth Filter Material____'�Z_e7_"/___._ -- Distance to nearest: Well---------------------------- �� -----Foundation------2X----------------.Property Line--- PIT [ ] Depth----------------Diameter------------_-------Number-------------------------------- Rock Filled Yes ❑ No WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance to nearest: Well----------------------------------.--------Foundation--------------------------Prop. Line------------------------- G REPAIR/ADDITION (Prev. Sanitation Permit#___-_.-_____________________________________„_..Date_._._________________.___ ) SepticTank (Specify Requirements)---------------------------------------------------------------------------------------------------------------------------------------------------------C DisposalField(Specify Requirements)---------------------- --------------------------------------------------------------------------------------------------------------------------- . ----------------------------------------------------------------------------------------------------------------------------------------------------------- - -----_----------------------- ---------�1` ---------------------------------------- ----------------------------------------------------------------------------------- -- - - -- ------------------------ ----------------------------------------- (Draw existing and 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: "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------I-A�!T/ Q�-------'�`...... ....................... -------------Owner BY -- - -------- - - - Title. than owner) R DEPARTME USE ONLY APPLICATION ACCEPTED BY - -- ------- - --------------DATE J� - DIVISIONOF LAND NUMBER----------- ------- ------------------------------------------------------------------------ -------DATE_----------------- --- ADDITIONALCOMMENTS-------- ---------------------------------------------------------------------------------------------------•------------------------------------------------------- ----------------------------------------------------------- ------ ---------------------- --------------------------------------------------------------------------------- ----------- ------------------------ ----------------------------------- ------------------------------------- ------------------------------------------------------------------------•-------------------------------------------------------------- ------ --------------- -' ----- -- ----- ---- ------ Final Inspection by.,. Date -- G ''_ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M