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FOR OFFICE USE: t�� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT9, —..... . ------- ------ (Complete in Triplicate) Permit No.-. - -...7-- Date Issued_1-5rl-/-- ."-- ---------------------------- .-...- 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. his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION /..------- /./�CT�L�.i�//� y �,�7..LG�/�( .FORD-CENSUS TRACT..__ .. _ ....._._....__. .. )wner's Name._.)_ R_ 1VW 10W. 41A-6--- --_........._... ........... . .... . .. ---------------- --Phonef.5'-? 9f.... -Address_.` / - --------------------- - - City----- .. -- --- ----- -- ------ _--Zip------ -- --- --- - ---- Contractor's Name._.....C9-WN-.2 IW,. .License #---------------------- --- -Phone................................. stallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other. ...:..._.._..._.. .. . J, o . lumber of living units:---/---------Number of bedrooms--,3..- Garbage Grinder .,..Lot Size__Z-2-0 Vater Supply: Public System and name--- -- - --------_ ---------- ------ --- ------ .......... ------ ------ --------------_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.) IEW INSTALLATION: (No septic tank or seepage pit permitted ! public sewer is frvailable within 200 feet,) / U ._'ACKAGE TREATMENT [ ] SEPTIC TANK D�J Size..-. _x_ _ ...'7.......... .............._Liquid Depth...... / �p Capacity.l0_6C� "Type.[ - ../........Material. .__ _ ..-_ ..- o. Compartments...... -_.._.i...-.--.---- Distance to nearest: Well__. Foundation. _ .-v._/.. _ ..Pro Line----- ....... -- --- LEACHING LINE No. of Lines .............Length ofle h line...... . ........Total Length .. .._./_0............... D' Box. .. Type Filter Material.�.v . Depth Filter Material__.__�..0.............____...___ i Distance to nearest: WeIL.__5U...._ ....._.Foundation.... ___. -----------....Property Line..__- .-- ------- SEEPAGE PIT Depth---oLS /Diameter.._. 3__ - -/.Number.___..U-Y - ._._._ Rock Filled Yes No WaterTable Depth--------------------------- ----------------------------Rock Size. -------.... - --------------------------- -- Distance to nearest: Well------------------------...................Foundation......__.....__.-.._..Prop. Line............ 'EPAIR/ADDITION (Prev. Sanitation Permit#-_.__........_..................... ..------.Date.......-._...._._.__.-.--.---------------- ---) peptic Tank (Specify Requirements) _-- --------------------- ----- ---------------------------------------._. ....---------------------------- --- -- ----- --- Disposal Field (Specify Requirements) .... ........... _ -------- _- ---------------------- --- - ..-----•------------- ------- ---------- ---------- ----------------------- .................. ---- -------------- ------- ........ .......--- -------- - - - ------- ------------- ------ --------- --------_ -------- --.....------------------------------------ ---- •--------------------------- - ------ --- --- -- --------.._..---- ------------ (Draw existing and required addition on reverse side) 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 man's,Compensation laws of California." Signed _ jl�--- ------------ - --- -_._...._...._Owner ,f� —By-------------------- r------------------------------ ----... - . Title....- ---- ----- -- -------- ------------ v (If other than owner) FOR DEPARTMENT USE ONLY �— DATE APPLICATION ACCEPTED BY_.._.'_ .---- -tom OF LAND NUMBER -----�--- ----------- ----------------- ------- ----...... - DATE------------------------- DIVISION - ADDITIONAL COM .-- - - ---- - -- ------- ------- - ---- ------------- --- - _' ---------------------- -- --- - - -------- .. - - -. ... . . -...... .-._.. ------------------------=------- ----------------------- ---------------- f ----------------- --- --- -- ---- ----- - -Final Inspection b .. ..................Date.__1��.-. - --- EH 13 24 SAN JOAQUIN LO L HEALTH DISTRICT F&S 21677 REV. 717