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FOR OFFICE USE: j' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Complete in Triplicate) Permit No.�Bn4� `3 --------------------------------------------------------- ----------------------------------------------------_.-- This Permit Expires 1 Year From Date Issued Date Issued-/a 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: f JOB ADDRESS/LOCATIOLLN.)_177 .70 j-----A-f'-.L_f--6?y- ------ -----------------•-------------------CENSUS TRACT.-------------------------- -- Owner's Name_d-,R-. V1!_VNP_Fr------------------------------------------------------------------------------ -------------Phoneol 5'.27-/.37 �r n/� - Address__.-7 1/------ �e�` "��'�----------------- ---------- ----- ---- ------------ Ci � ��' tY �' Z i P Contractor's Name- .- 1 ---/ -- tzl? -�YL � ------------------------------License Installation will serve; Residence X Apartment House E] Commercial []. Trailer Court ❑ Motel ❑ Other----- ----- -------------------- W--- ' Number of living units:-----�.---------Number of bedrooms---�-----Garbage Grinder-__-_____--Lot Size-----w __-_______________-_-_- Water Supply: Public System and name------------------ --------- ------------------------------ ---- -------------- F ------------------------------------------Private -Character of soil to a depth of 3 feet: Sand r] 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 i� available within 200 feet,) Nt PACKAGE TREATMENT --------------------------[ J SEPTIC TANK ] Size-- ��-��- -- T e------------ ------- Material--- - ----No. Compartments e_---- -- ------------- ---� CapacityI�Q - YP �. LiquidP '� Distance to nearest: Well.--.--f Q________------_---------Foundation.--_.��-------------Prop. Line ---.--. LEACHING LINE [ ] No. of Lines..---...�._ g 6 1 0 R Length of each fine. Total Length._f- ------ --------------------- l1 � �� 'D' Box----/------Type Filter Material-/J/Y- Filter Material------19-------------------------------------------------- I J Distance to nearest: Well---�ak;----------- --Foundation- F�-- --------------- -----_---- Property Line.-.-._-.-------------_--.-.---____-. SEEPAGE PIT Depth--Water Table Depth -- ~Number--.- da-------- ---- ---- Rock Filled Yesg No ❑ --- Diameter--- - P ------------------------------Rock Size--- -------------------------------------- f = Distance to nearest: Well---4--Q�__-_ `-- ________________Foundation-,__f_a .-----------Prop. Line 1 REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date---------------------------- -------------------) Septic Tank (Specify Requirements) ----- -------------------------~--------------------- --- ---------------------------- Disposal Field (Specify Requirements)-------------- ------_---------------- ---------------------- --------------------------------- ---------------------= ------------------ ----------- ----------- -------- ------------------------------- ------------------------- ------------- ------- ----------- ----------- ---------------------- {Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that`tlie 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 n6t.employ'any person in such manner as to becom b'ect to W rk/�an's Com ensation laws of California." Signed__ -----I--- - - ---__47 5617, -------- ----- I � B Y-------------------------------- --- - --- ------------------------------------------------ - Title--•------------------------------------------------------------ ----------- (If other than owner) R D PART) T E ON1,4Y APPLICATION ACCEPTED BY _ __'_;- _-- .---...- ^""y"' DATE...- - -. .-.-.� 7 7 ------------------------------- ----- ------------------------ DIVISION OF LAND NUMBER.--," ---- ---- --------- DATE. --------------------------------- ------------------ - ADDITIONAL COMMENTS------------- ------------------------------------------------------------------------------------- i ----------------------------------------------- r --- ---------------------------------------------------------------- --------------------- --------------------------------- ----------- _ ---------------------------------------------------------------- Final inspection Y - = = Date �----------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ra 21677 REV. 7/7f 3M ection b