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FOR OFFICE USEO�� "�'�� � '� " FOR OFFICE USE: <br /> E-M- APPLICATION FOR SANITATION PERMIT <br /> ... .............. Permit No <br /> .................7 .. <br /> � (Complete in Triplicate) <br /> rl <br /> -'"-' "--'-- " Date Issued-,�a.-��.."�� <br /> ........................................ ................ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.. .... R Q T / -Z- TvMe .CENSUS TRACT........____--.-_------. -- . ............... .._ _........---------- ---------- <br /> Owner's Name..-- ---- D.y ve .may-so n� <br /> . ----•---- ..---••-. Phone.-... _- .-- - - <br /> Address------- 3oJ 000 ....../S�e`JssoN..R / -... Cit 3YN�------- --- ---_--- --Zip--- --- <br /> Y <br /> Contractor's Name Aw-TvIYy.-.'`..._%per License #./66 5&' Phone_.5. -3'y� <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------ ----------------------- --_----- <br /> Number of living units:-----J.......Number of bedrooms....1__ Garbage Grinder-...........Lot Size--------------- -..- <br /> Water Supply: Public System and name._-------- ------5 cTl--A' ----................•---..-.-...-...-...........-_...-_----- .............Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material.- _.If yes, type............_-.---:--- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) _1�3 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size ............._._......----------------------------------Liquid Depth.-.........---------------0 <br /> Capacity_ AC-0.___Type.Rye..6A.s 7--Mate-rial....GCompartments...... ------ <br /> Distance to nearest: Well........ ........:Foundation.......!.Cr.............Prop. Line..-9A- <br /> LEACHING LINE [ J No. of Lines --_.Length of each ----- -Total Length _ _------------- <br /> Arex 'D' Box... ..___Type Filter Material ....Depth Filter Material__ ........ --- <br /> Distance to nearest: Well---------------- ----.-----.Foundation..... ................Property Line... I----.--------------------•-` <br /> SEEPAGE PIT [ ] Depth---____ _-._Diameter.......".--------...Number.------------------------------- Rock Filled Yes ❑ No❑�] <br /> WaterTable Depth............ .-.. -----------------Rock Size_.- __..----------------- --_--------...- <br /> Distance to nearest: Well.--------•---------- -------- -- Foundation..... ----------..........Prop. Line........ ------ ---------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------- - ---- _----.--... ............Date--_-_-_---------- -----) <br /> Septic Tank (Specify Requirements)------ ---- ........... •---- ------ _.-_------------------.......... <br /> Disposal Field (Specify Requirements) ..__...-_-... ------- --------- <br /> - - - ---•------------ ........ -------------•- ------------- --•--------.............------------ --------- ------ --- -- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "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 <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-----. •.A ..�A ��d 0- -- - ---------•---- ------ -------------.Awner <br /> BY----....... Title---------------------------------- ----------• --- ------ <br /> ( ther than owner) <br /> FORJ)JPARTMEN SE ONLY <br /> APPLICATION ACCEPTED BY,� .. ---_----- ------------- --------DATE -- - �-- -------- <br /> . -- --- - - -- - -- ---• <br /> DIVISION OF LAND NUMBER------------- - --------_- DATE..- <br /> ADDITIONAL COMMENTS - <br /> -------------------------.. -------- ------ .......I --------. _.. -- ----- ................ -----.....-- ....... ---- ----- <br /> ....... ------------------------------- -- -------- - <br /> .................... ------------ ..... r ------­-------- ............... - 7,- <br /> Final Inspection by: � �-' L� ��=t-----------------------------------------------Dat <br /> '-' f&5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />