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FOR OFFICE USE. , ..._.. t APPLICATION FOR SANITATION PERMIT IComplete in Triplicate) Permit No. . -7 S This Permit Expires I Year From Doto Issued Date issuer! ..f:.y y. - 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 malde in compliance with County Ordinance No. 549 and existing Rules and Regulations: f JOB ADDRESS/LOCATION .._... _.��. .. .. ._..•...,i._. .— ) ...............................CENSUS TRACT Owner's Name ...__�'P,7.c . •e/:�- £'/..!' f. .......... Z5 Address -..�..-.•... / ....f ..._ -I One . ....... .. .. ....._. ......._.._. i ,: tel._ ,...... . ....._ City';P �-awl....... Contractor's NameLEeense91 Phone .2' :v. Installation will.server Residence }.Apartment House Commercial Moller Court 0 I Motel ❑Other ............. Number of living units:::.- __.. Number of bedrooms 2......Garbage Grinder ........ . .. Lot Size .......:...........• Water Supply: Public System and name ---------------•------ - ._ € -- ..... ............. .........................................Private ❑ Character of soil to a depth of 3 feet: Sand[_] Silt 0 Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ Hardpan [J Adobe 0 Fill Material ............ If yes,type ............... f (Plot plan, showing size of lot, location of system in relation to wells, Isuildings, 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 1/ l Size. Lt> .1` d .._...— Liquid Depth . Capacity] ....... TypeAc-P- Material --- -------• . No. Compartments I'I .yam ---- ...........Distance. to nearest: Well --------Cy..0-------------i -•Found ion _-�_a.� Prop. Line . . LEACHING LINE [ I No. of lines .._._..._. N ----------- Length of ea ' fine..... ---_----------------- Total Length 'D' Box ....f..._... Type Filter Material ........ .....-...-. Pth .Filter Material ......_............_ i Distance to nearest: Well ...................... ,'Found ion Property Line . ... . ... SEEPAGE PIT [ 1 Depth ..._...-----•------- Diameter . Nu_ •;,,--- Nu er ............... .. .... . Rock Filled Yes ( + Water Table Depth ' -•-----•-••.............. - Rock Size ...................... ' Distance to nearest: Well ..:............ ...... J K':.. _...._Foundation .................... Prop. Line .......(Prev. Sanitation Permit# ............. ----------------- .............__ r' � Date __......._.._----- �p Septic Tank (Specify Requirements) _..:_..__..•...__. .. .....................:.........................._-•---- ...... ....._ ._.. . ... ... .. Disposal Field S city Requirements) ... ..__--.f ------�� --- s --- -- ------ 'IDraw existing and required addition on reverse side) ................................... .. ! hereby certify that I have prepar ........ ed this,application and that the work will 6o done in accordance with San Joaquin County Ordinances, State Laws, and Rul s and Regulations of the San Joaquin Local Health:,District. Herne owner or liten. sed agents signature certifies the following: "I certify that in the performance ofsthe work for which this permit is issued, I shall not employ any person in such neannor as to become subject to Work an's'Compen sation laws of California." Signed -- Jf - Owner By ---------- --- .----- --- ----------•- . xitle ------ ._.._.-..... _..._..... - (if other than owner) ...... -- R_DEW INT USE ONLY APPLICATION ACCEPTED BY ............. DATE .. ................................................... r BUILDING PERMIT ISSUED --_- -----_- .... D!TlQNA COMMENTS ------------------------------------------- -------------- ---- DATE'- ------------------------- - -------• . t •------•------ - ------ •• -----•-----_-------• -•------...__. .................. .................................. -------•-- --------- --- --- Final lnspee inn hy: .. ----------•- ---- .......................... .... . . �7 ------ ---• •-_---__-Date _.�`r... .�:./.::._:......::.::: i Ex 13 .2L 1-613 Rev. 5H . SAN JOA IN LOCAL HEALTH DISTRICT 8/7a 3M I