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* FOR OFFICE USE: " F OFFICE USE: �- APPLICATION FOR-SANITATION PERMI ao, ---------------------- ---------------------------- -- -- ��- (Complete in Triplicate) © � Permit No----------------------- �- 7,f Date lssued_�: _____ ------------------------------------------------------ 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 CountyOrdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION 2/0,N-- ---- 1,1,4-'o_4---- C,G -------------------- -------- .--.CENSUS TRACT-------------- -- _-. Owner's Name. 9 6 ,}_��`s_°` 5---------------------- ----------------------- ----------- -------------Phone--�-- 5d- 3 ` Q Address--------------------------- -------- 15-4 J --------------City-----6_5. e1_b.kn----------------Zip---1.53.a_0------- Contractor's Name----------------O&P-'ti-------- - e k-5 -'—----------------------License #_ -St` -----Phone- -_z15a-----. Installation will serve: Residence Apartment House.F] Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------------- -------- - Number of living units:---- /------Number of bedrooms-.3-------Garbage Grinder-1-6-_--Lot Size------r1-_�t_./ C_r�S_____.__.___,.___--_____.-_. t Water Supply: Public System and name-------------------------------------------------------I ------------------------- _-_-Private f� Character of soil to a depth of 3 feet. Sand ❑ Silt❑ Clay [A 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,) (yam PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------ _ (1 Z--------CJ_-4-L'-----------Liquid Depth.__ Capacity-,l.-gVO..1_-t ype--Ajr��'CW§F_- Compartments----' ....-------------------------�c Distance to nearest: Well------5QIF--------------------Foundation---4Q---------------Prop, Line.-----Apo__-___.--. " LEACHING LINE [ ] No. of'Lines--------2---------- Lengthof each — _ ch line-- b ---.___._ .Total Length-------- _ __ _d________________ 'D' Box-------/__Type Filter Material__Pi,_A00_t epth Filter Material_-_-__-- - -4�----------------------------------------- Distancato nearest: Well__-5-Q_.�---------Foundation----- --_ _.Property Line._.-- -------------- SEEPAGE -d--_SEEPAGE PIT [ ] De th__�L/__._-Diameter_ -/`2.____Number--------.i�- .-----_-___ p ________ Rock Filled Yes LX No ❑ Water Table Depth-------------------------------------------------------- Rock Size----- --/L'3-'-_/PQ tx-------------- Distance to nearest: Well...../-0.4_ ---------------- Foundation---4-s_--e__-_--.Prop. Line-------- -----------r------- - REPAIR/ADDITION (Prev. Sanitation Permit#------------------------ ----------- ----------Date ------} S SepticTank (Specify Requirements)--=------------------------------------------------------------------------------------------- --------------- ----- --------- ---------------------------- Disposal Field (Specify.,Requirements)------------------------ --------------- ------------------------------------------------------------------- ---- -------------------- f ------------------------------------------ --- --- ----------------------- ----------------------------------------------------------- -------- --- ---- ----- ------------------------ (Draw existing and required addition on reverse side) t I 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 "I certify that in the perfor ante of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to km s CompAnscition laws of California." ---------------------- Signed---------------- - .°r'G Owner BY E � ----- ---- --- ---- ------------ (if ~ other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ --- -- --- -- ----------------DATE----------^----- -7 "--------- DIVISION OF LAND NUMBER -- -- ----__ -------------------------------------- DATE_.-_-..__-.-._-._.-_ ---------------------------------- --- ADDITIONAL COMMENTS-------------------- --- --------- ------------------------------- ---------------------------------------------------------- -------------------------------------------------------------------------- ---- ----------------- ------------------------------------------------------------------------------------------------------ ------ - --- ------ -- - FinalInspection by:--------------------------- - --------- - -----------------------------------------------Date--- --V -_-P------ ---- E11 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 1=as 21,577 REV. 7/76 3 t