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Coos k�� a 3o�ODD IC ORO CE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT `� --- ----- (Complete in Triplicate) Permit No.__7Z------------ ----------------------------------------------- -------- Date Issued---- ------------------------------- --------------- --------- ssued____--------------------___...___.________-__.._-___--- 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 Cpggtt Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION- +n / `C" ` SToA� '------- 9; e-__CGUC�NSUS TRACT------------------------- ----- Owner's Name----------------- 3v -,;/-- -------51 <Y O S---------------------------------------------------------------------.Phone------------------------------------ \ Address 30 --- /Y-A-------------------------------------------City.._x;eq-C-------------------------zip--------- -------------------- Contractor's Name--------- r--- !IlTlltlll_ - -tom Se>� License Installation will serve: Residence [M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------------ of living units:-------- ------Number of bedrooms-----1------Garbage Grinder------------Lot Size----- _1 a -----------------------______ Water Supply: Public System and name---------------- ----s'c3' / ..C'.--------------------------------------------------------------- ---------------._Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Lk Hardpan ❑ Adobe ❑ 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.) C d NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-.--------------------------------------------------------- Depth_---------------------- el Capacity-_/_��r-.-----Type_ 3w-----CAfrMatwial----COeV ------No. Compartments----;2+---------------------------� Distance to nearest: Well-------------------------------------------Foundation----4G'--------------Prop. Line---_'.~___.__...._.___-� LEACHING LINE [ ) No. of Lines.._�WAV?'__$° ength of each line.__X-47__ _____.Total Length ________________.--..-______________ CD 'D' Box--.-/-----Type Filter Material-_�—__Depth Filter Material__-3a__`_------._ Distance to'fieorest'Well-- ----- ---- - --'..___Foundation__ 8.�_ .____--_.-Property Line ---0-- SEEPAGE PIT [ ) Depth----.-----------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth----------------- ---------------------------------------Rock Size--- --------------------- ---------------------- Distance to nearest: Well--- ---------__---------------------------Foundation--------------------------Prop. Line--------------._____--__.__. REPAIR/ADDITION (Prev. Sanitation Permit#-_-__________________-__.--_.................Date__________-...._.____-_______._ _) SepticTank (Specify Requirements)-------------------------------------------------------------------------------------------------------------------------------------------- --------- DisposalField(Specify Requirements)-------------------- - ------- --------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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---------- A --/��N- - -- ----Ae-/Y----------------------------- Owner BY--------------- -- -- --- !-- - ---- ------- ------Title------------------ ----------------------- ------------------------------ (If o er l caner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - - ---------- ----- -----------------------DATE.----- DIVISION OF LAND NUMBER. ----------- - ------------ DATE ADDITIONALCOMMENTS---------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------- ------ --------------------------------- --------- - - Final Inspection by: ----- ---- - Date. . �2-- � EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/76 3M