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FOR OFFICE USE: 1PLICATION FOR SANITATION PERMIT FOR OFFICE USE: .....................:................................... Permit No..,e -/IV 4Z (Complete in Triplicate) ..................................................... ... Date Issued.. 1-2,9 ._-•............................................... ..... 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. r This application is made in co'm'pliance with County O1rdinance No. 5499 and existing Rules and Regulations: ' Y JOB ADDRESS/LOCATION....:W"1. .-I..O._.,......._S.7..0_N_e.tC1..C11.-�.e-..........................CENSUS TRACpT....................0........ <` Owner's Name.....�. ..........1.:.\.0..?. ....... ...,......... ....:.f.,,........--rr-:..- ...:.._....s. ...__:....,__....,.,Phone...CQ. 1... t� a - - 2 Address...J.a 1.........U0......AA r Cityt-.Cj,..C�....... zip...9.53!71 ...... Contractor's Name-----k. ....Ae....... ............................License #.19.. 73..Phone-R-U-CFA3.01 Installation will serve: Residt rice Apartment House Commercial ❑ Trailer Court ❑ Motel,[:1 O her......_...._.....--- --- ........... 1 y� Number of living units:....... .......Number of bedrooms... .__..G r age Grind .._.Fv..,..Lot Size........ .... ..Y....A........................... Water Supply: Public System and name.......:................... . ...... .. . ....... . ..... ..... .. ..........................................................Private( Character of soil to a depth of 3 feet: Sand ❑ Silt' y' at Sandy Loam ❑ Clay Loam D4 Hardpan ❑ obe ❑ it eri .. ....... f es,type................................ (Plot plan, showing size of lot, I«ati n of sy to in re do tow IIs, uildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or pa p- permitt- if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPT TANK 1 Size...-:.......,\-------............:....�.."..' 0 ...............Liquid Depth -..........._............. Capacity.. 4.�, pe .............i.......Moterial...��01VXr.r.--T . Compartmepts.-----a..........................� Distance t ne st: ell ... ...... .......................___.Foundation...J.Q!..:1._...._.....Prop: Line... LEACHING LINE [ ] No. of Lines...,.....' ; ..........Lengt h of each line.........9.0.._. .......Total Length.....�.. �....,_...:: ......... 'D' Box._.. ..,-.,.Typ Fil er Material.l7Z'.,l.tJc,ADepth Filter Material,_._.__1_.9...................................................� Distance to neares : Well..... X)v.:...........Foundation.....5-L7----------:...Property Line ../0..........................� SEEPAGE PIT [ ] Depth..:...: .......Di meter ....... ...........Number................................ Rock Filled Yes ❑ No ❑ WaterTable Dept . '..... --... ......... ..............................Rock Size................................................................... Distance to nearest: ell-. ...... .............................Foundation------....................Prop. Line................_......... REPAIR/ADDITION (Prev. Sanitation Permit#.....:.:...........................................Date..............................................) ' Septic Tank (Specify Requirements)...................................... .......... -------...............:.......... - . ............ ...................--- Disposal Field (Specify Requirements)...................?(' ........ .................................-....... . .....................- _.... - ..........-- .. ......_.............. ..........--...............---.......... ._.........................................._. ......_..._....... . ....._.....--------..............,.... .............. ..................... ...............I................- -'.. . ...................'-----------------r .......................... . .......--- . -----............._............... (Draw existing and required addition on reverse side) I hereby certify that 1 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 :loaquin 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 ys biect to Workman's ompensation law/.s�of California. Signed... `-...........:...... .. :•. cs:<, /-�rG, .. By..........................................r------ ......- - ..........-.._.. - ...........�Title... ...................................................._....... . . ... (if other than owner) .t - TR DEPARTM NT NLY APPLICATION ACCEPTED BY....... ... .. .............DATE.... ...._.... . r DIVISIONOF LAND NUMBER........ %........ .......................... ...................................................DATE..........,................................ ADDITIONAL COMMENTS............ ' .............. .....:::.. .................:.............................................................................. ----------- ......... ................................:... ............................. ..-`-'---------.............................................. ... -- ........ -- -_.._....._.............:.............. ............................. ....I.. ------.........................---........_...._......._............. ..... -- .._.......-- -- -- ----.................................... --- ..... ..... . ............. . . ............-----...... . ........................------........_................... - .................... --.•..................-----........................................................... .. . FinalInspection by:......................... .............................................................................................Date....... ........................ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 arv. 7/76 are c4q2�