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FOR OFFICE USE: t/. FOR OFFICEUSE: PLICATION FOR SANITATION PERMIT pO9"D ..............................................-----.--. ` (Complete in Triplicate) ---' Permit Noz .."�' ""p _. 1. Date Issued..a7: .::7/ T ...............................:.......__..,.... ...... , This Permit Expires 1 Year From Date Issued Application is hereby.made,to the Sari Joaquin Local Health District for a permit to construct and install the work herein described N This application is mode in complionee with ,County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION/..�,.].,�.►`i' 6. (:.. .R.IIJ. /�[./II ..... lCl'................._.......CENSUS TRACT................................ Owner's Name.... .......(.:.1.d.5 / . :. /'�._,.....':.._,.._...Phone...33J ......................... Address..5. .l.._tt It.,..............sT.�.................................. City../C�i..... Zip 7J� 5..7.------- Contractor's Name/.).e. e- CC?, �ll✓e' `� _.. License #.v�. -.. 51.13.Phone...D�?�� 2' J---.... ldt�! gT - ---- . .��........ . Installation will serve: Residence Aportmept House C) Commercial ❑ Trailer Court ❑ Motel ❑ Other............... -- 1 Number of living units:.....J........Number of bedrooms..3.....Garbage Grinder..._........Lot Size...I. ....110.5'..................................... WaterSupply: Public System and ngme.................................................................. ...... .... ................... . ..........................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,) PACKAGE TREATMENT [ ] SEPTIC TANK J Size..�i1f �.... ._.. ...... . _ ..:.. . ....Liquid Depth...... ................... c Ca pacityl�� ..�. .Type........,:- Moterial.4 4%.Y.e4R.(!15No. Compartments......% ...................... ` Distance To nearest: Well...CZy............ ...................Foundation..... '---------Pro. P. Line....6 .............ell: i G LEACHING LINE [ ] No. of Lines...... ...:...::........Length of each line.........f.c.,.....,..._.Total Length ... s2.. Q........................ e. 1 'D' Box-----�.....Type Filter Materiall�?.t O.SFeDepth Filter Material-`9 ....................................................- Distance to nearest: .....Foundation.;.; .: . Property Line.... �.�....................... SEEPAGE PIT ( ] Depth..:....... ...................Number................ ..._........... Rock Filled Yes ❑ No❑ Water Tab]p Depth............. -;........-------..:_.Rock Size............-:.................................. 4 ;r , Distance To neorest:.Well.............'_...... `..................Foundation..........................Prop. Line................._......... REPAIR/ADDITION (Prey. Sanitation Permitil ..................... Date.................--.-----------,.............. 1 Septic Tank (Specify Requirements)---..:,,. -- .: . .. -- . •....:..'. .... Disposal Field (Specify Requirements)............... r;_.... ................. - -... .._..... ----............................. ................ ..... ... t ------•.................................._...... . ... . . ..•---..-,.....---- ...-......... ................ -�...................I..............._......................................... (Draw existing and required addition on reverse side) I 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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: - - "1 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 bb' ct to Workman's Compensation laws -of California." Signed---1..)..!.-K.<....../LLC.cEfYtv!^`�`'/...1 rJ>! v. ...... ner By............ ............................ .. . .....:._.......---- .. ......... ..................Title............_........ ..........,........... ................... (If other than owner) FOE DEPART ENT USE ONLY APPLICATION ACCEPTED BY -- ....::......................DATE . ...`. .. V7:7_7.................. DIVISION OF LAND NUMBER ... ........... - .............: :.................................DATE...._.:..._...... ............-- ......... ADDITIONALCOMMENTS....................:j................_....:.,:.....................I--------- ..................-...........................................----------------------- .............. .................... ......................................t-.........................,.....---.................. ........................................................................ . ............I ..................... ............ • - ------ Final Inspection by:..... .......... - f'j/L;/........ .............._............... Date..... ...-. .-.. EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6s 21677 RE . 7/76 3M W