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_ w FOR OFFICE USE. FOR OFFICE USE: .00 APPLICATION FOR SANITATION PERMIT p�,� I' (Complete in Triplicate) Permit No.. - --.- P� --------•----------•---••----------•-------------------- mac- ,FF..... . 7 d . ........ ......--•----•••.---- -------------- This Permit Expires 1 Year From Date Issued 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: r JOB ADDRESS/LOCATION CENSUS TRACT..------------------------------- ...7 . ........ - Owner's Name.. ...Phone Address.. ... ... ........ .. . '~------- CF - city p , Contractor's Name..._�J�.. C.. uy ................License #-,'341 .-...Phane.47-4/104_e.,-'7 ,, 11 6 5 Installation will serve: Residence Apartm nt House ❑ Commercial ❑ Trailer Court ❑ tel ❑ Other......-- --- ------------• ------- 4 1"C7 Number of living units: ......Number of bedrooms---- Garbage Grindar-.-..-.-.._Lot Size....... .X/410.'.-- _......... . .. Water 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size..... y YY .........Li quid De th._. ------------- - --- q P Capacity.Ner-----Type...- Material.- �j-...-.---• -No. Corn partments--�.......................... Distance to nearest: Well- �� . -------Foundation-- 1 ..Prop, Line.. f1P- LEACHING LINE ( ] No. of Lines _... ........Length of each line ...C_lp ........-- Tota! Length -- ......................... 'D' Box_...r-. - Type Filter Material- -f ---.Depth Filter Material_./.�---------------------------- -------- --- ----------c Dist est: Well--- Foundation. Property Line.... [ ] D 'pth-..Y/l��}'�z�ia eter............. ..... Number_.,.------------------- Rock Filled YesX No ❑ L� e. .�,/O � epth .....- Rock Siz Prop. Line-G Q . -` Foundation Distance to nearest; Well----- REPAIR/ADDITION ------ Septic ... I (Prev. Sanitation Permit#----------------------------------- ---------------Date.---.------------------.-- .------- ------ Septic Tank (Specify Requirements)..................... .. ._ ------------------------------ -----• } Disposal Fie (Specify,Requirements)........?-------------- • - ----------- - ------ ..........----•-- --------- % (Draw existing and required addition on reverse side) 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 performance of the work for which ihis permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." of Signed-_ -------Owner By........... �`-�L' . Title--- -- ---------------- - ---------------- -- ----------------...... (If other than owne -- ._- - - OR D ARTMENT USE ONLY APPLICATION ACCEPTED BY...-- DATE 7 .....---..:. - DIVISION OF LAND NUMBER ......... ----------- ------- •-•------- ------- - DATE.......... ....... --------- --.. ADDITIONALCOMMENTS--------- --- -------- ----------- ......-- . .. ---------------------------- -------- ------------- ------------------------------- --------- --------- -------------------------------------- --------- ............. .- ...---...- --••--•-•----••-•------------- --- - Final Inspection by-- ......-------- ?..- `-.. - - Date. _ -1.�...:.... 1EX 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M