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FOR OFFICE USE: FOR OFFICE USE- APPLICATION SI-APPLICATION FOR SANITATION PERMIT ------------------------------------------ (Complete in Triplicate) Permit No._7f---__:_3... ------------------------ ---- - _--------------- ----. 4 r. _ __�._- __.....: --_....—_ -_ Date Issued._9-_a_1__,g . ____________________________.-- This Permit Expires 1 Year From Date Issued &,o Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thework herein de cribed. This application is made in compliance with_County �Ordinance No. 544 and existing Rules and Regulations: � 1 JOB ADDRESS/LOCATION. ' S'ire n �• y------------- -- ' --- ----- T --� CENSUS.TRACT Owner's Name-------�0? - = 13-� v- ..: ----- ' --- -Phone.--------- -k---- ------ - ---- - - - - ------------------------------------------- Address___.3__b,cOo �f --------- --so/-/-------------------------------------- '-------_ --- City- �y `�c - ZAP - --E---- r L v.� _._:E'_.._479.e-------` - ------License #_J66_" 5�6, Phone-- 3.T 3 Contractor sName__-._-_.�__�_}_-_ T/7 • _ � Installation will serve: Residence] Apartment House ❑ Commercial ❑ Trailer Court ❑ ., Motel ❑ Other--------------- ----- Number of living units:_°__1----------Number of bedrooms__-_`_.._._Garbage Grinder-------------Lot.Size-------------- ------------------------- `_.- W Water Supply: Public System and name_____________5�_�__`_-� C' _____ -.--_---._. ate 1 = Priv ❑ O Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam F (1�i 7 Hardpan ❑ Adobe ❑ Fill Material.....-------Ifyes, type------------------------_ __ {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] Q NEW INSTALLATION.— (Noseptic tank or seepage pit permitted if public sewer is available within 200 feet,] > PACKAGE TREATMENT [ ] SEPTIC-TANK [ ] `'Siie------------------------------------------------------- -Liquid Depth.;----- -------------- Capacity__12.b _ Type -� C✓�f/.Material_-- Coltfc No. Compartment s------�--------------------- Distance to nearest: Well:_..""________ __ _____________1___--._Foundation.______ __ -__- _.'__Prop. Line__S.__ I C # .�o '- d y40 ; S �T LEACHING LINE:.. [ ] No, of,Lines_.___.______ Length._,.._,____. of each line._____"._:X�f, _ ,;. -.,Total Length- . _$ ____ __ _____ ;D' Box---I-------Type Filter Material__-_-- ____Depth Filter Material _ �_ ] ______•_____________ __ Distance to nearest: Well_______________R_.�* _.F _ __ � Line_ � 1 oc ' � a oundation--------/6 - -Property `'------------•--------- - -- SEEPAGE PIT [ ] Depth___'___-.--.___Diameter--------------------Number.--_----- --------'_-----_ Rock Filled ;Yes ❑ No F. { Water Table Depth---------- "---------------------i--,-------------- -- Rock.Size---------------------------------------- -=------ Distance to riearest: Well---------------------------------- ------Foundation---------------------------Prop. Line------'-_------------------ REPAIR/ADDITION (Prev. Sanitation Permit#--------- --- ---- --------- -----------------Date. - Septic Tank (Specify Requirements)----- ----- ---•---------- I - .-- ----------------------------------------------- ------ 1 Disposal Field.(5pecify Requirements) _-- .,. ------ -------- -------------------------------------------------------- ----------------------------------------r - - F ------------=------------------------------------------------- ----------- ------ --- ------------------------------------------------------ -------- ---------------------------------------------------- } . _ tj -------=----------------=-----------------------------------------------------------------------------` --- ------ ----------=----------------- -- ----- ------- {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 Countyh 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.Workman's..Compensation laws of .California.', t i � I _ Signed T -�� ---- So = :: -'---Owner x - } BY - --- : - --- -- ------------ - Title. ---- -------- - --- --- - (I of er thani owner) i j FOR DEPA _.�ENT USE ONLY APPLICATION ACCEPTED,-BY._ = --------- ------------ -----------DATE.- :l_-:_. -. ' -------------- f DIVISION OF LAND NUMBER = = ----- DATE.---- , - =r ' ADDITIONALCOMMENTS---------- ---'---- ----------------------------- ------------=- ----------------------------------------•-•-----------_------------- _ ---------------------------------- ------------------------------1 -------------------------------.-_------------------: ---------------------------------------- . . .- .. ' ----=-- ---- ------ --- ----------------- -------------------- - --------- --- ------------------------------------------ -- ---- - ----- - ---- Z Final Inspection by:---` -- --- --- - Date.-:: -_ � E EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&S 21677 REV. 7/76 3M r.�