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P61Z OFFICE USE: UK V111 9ASn ! FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 7_ S7 r - (Complete in Triplicate) Permit No-- - ------- ------ Date Issued____ __1, --------------------------------------------------------- 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---; �_&0Q----,---- ---------------------------------------- ---------CENSUS TRACT----- ------------------ - Owner's Name---- i9 __fOeg�'sliv �' _�z" Glu � -- --------- -------------------------- -----------------Phone-------------------------------------- Address---3_oo�M_15 --- ------------------------------- Address---S_/_�M_15------------------------------------------ -------------- City--7�` c� J`----- Zip Contractor's Name_-J05",Ar1l7 vN7---f---0'o,eV-----------------------------------License #_/�6-j '�-------Phone- Installation will serve: Residence❑ Apartment House.0 Commercial ❑ Trailer Court ❑ Motel ❑ Other----C_,-91 ___CiWO!vlY -_ Number of living units:----------------Number of bedrooms------------Garbage Grinder------------Lot Size___________________________._.___________.______________ Water Supply: Public System and name--------5'� "< 8, �-` --------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ® Clay Loam ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ,�1 PACKAGE TREATMENT [ ] SEPTIC TANK [ j Size___________________________________________________Liquid Depth---------------------------0 Capacity-------------- ------Type---=------------------Material--------------------------No. Compartments-----------------------------------Q Distance to nearest: Well.-----------------------------------------Foundation-------.------------------Prop. Line----------------_______---_ b LEACHING LINE [ ] No. of Lines------,-----------------------Length of each line.------------------------------Total Length._____ G D' B»ac r:.'_Type Filter MRterial---------------------Depth Filter Material______ ________ -;•`Distanceito nearest: Well_____,__ _ __ __ :_____Foundation___ ____.___ __________Property Line----------------------------------- SEEPAGE __- ___ ______ ___ ________SEEPAGE PIT [ ] Depth__y_.`_ -------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑N Waterta,bje'Depth---------------------------------------------------------Rock Size------------------------------------------------ P Distance J6 tle&est: Wei l__ ______._____ _____ ____________Foundation--------------------------Prop. Line---------------------------- REPAIR/ADDITION-(Prev. ___ _ _____ _________-REPAIR/ADDITION-(Prey. Sanitation Per,rnit#---------------------------------------------------Date_________________-_.____________________) Septic Tank (Specify Requiremenfsj_______A_ *ft .,,A&44 _1r ------------------------------------------------------------------------------------------------------------ -------- Disposal Field(Specify Rgq Item-ents)__=-__3x00--__A--N---------------------------C� l -------------- - --------- ----------------------- ---------------------------------------- ------------------- /? y c ------ ---------- 1tic�/ ' �1/ Tai L e TS r 4` C, T'-----w 'eft------mac/----- � ��----��-ti��-------b --S ---�"--�__---------- ----------------------------------------------------------- (Draw existing and required addition on reverse side) 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Roles and, Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the pfrformanee 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---- 7, Dr Se�f Owner ------ -------- t7" By----------- - -- --- -------------------------------------- -----------Title-------------------------------------------------------- --------- ------ (if r than owner) FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY -------- _ ------ ___ --------------------------DATE._ 1 - ____________ DIVISIONOF LAND NUMBER--------------------------------------------------------------------------------------- -----------------DATE------------------------------------------ ADDITIONAL COMMENTS - - --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ ----------------------------------------- ---------------- ------------------------------------- ----------------------------------------- -------- -- ------ ----- - ------------ - ----------------------------------------------- - Final Inspection by:-------- ---- --Date--------------�� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M