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FOR'OFFICE USE: FOR OFFICE,USE: ` -------------- t-- PPLICATION FOR SANITATION PERMIT / -------------------- LL J e - �„ �v (Complete in Triplicate) Permit ---�-- ` � . t Date Issued -� ✓�7y ------ --- ----------- 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA ION--- Q �'' 'YZ. °e --------_--CENSUS TRACT = `. T f ¢ - Owner's Name.-,, =.: ..:: Phone-- _ = S� Address.3,g4'_a--- -- �.� ' --- -------City-_ Zip s Contractor s N r ame G Li one S ��-- i ----- -------- --------- --------=------=-- - 'cense #�7__C 5--� - -Phone-;Ph - Instaliation,will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ ;. . f• Motel ❑ Other,__.__:------------- ------------ = k Number of living units.---./-- -Number bf bedrooms___ -..Garbage Grinder------------Lot . .__-_----------- Water Supply: Public System and name------- .--`._. -----------------------_ _:=_=- ---.^=-_.------- -- ----------------------------------- --------------------Private Character of soil to a depth of 3 feet: ZSand C] Silt 0 Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ � R Hardpan R/ 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 Tpit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK' 4 r ------------------ [ ] Size -- -----=------- -- - --------Liquid Depth --- --------°---- i - Capacity--=----:= =_-----Type Mateal---'------'----------- -I No: Compartments------------------------------- -� Distance to nearest: Well ------ __...____: \: Foundation---------------------- --.Prop. Line ---------------------- LEACHING - ------------LEACHING LINE [ ] No, of Lines:----------------------------Length.of each line__----_-------------—--------Tota 1, Length --------------------------_------"__,__ c t 'D' Box------------Type Filter.Material--------------------Depth Filter Material---------------------------------------------------- "`— i:. V- -,. rDistance to nearest:-Well-------- -- =__-- - - -Foundation s __--------__-Property Line-------------- ..:......-.-..__ -----------------� k SEEPAGE PIT �. [ l Qepth____..__-.- Diameter-=------------------Number-- `------------------------- Rock Filled Yes E] No[].Z Water Table Depth'-_'------ Rock Size-------=---------------------------------------- Distance = -Distance to nearest:Well--__---.`-.---_r------- ------______ Foundation------------------------- --- ._,Prop. Line---- ----- -------- REPAIR/ADDITION Prev. Sanitation Permit#--°----- _,---------_--------s - ---------Date------ ----------------------------------- Septic ------ -- ---------------Septic Tank'(Specify Requirements) ---------- --- -- --------------- - ' Disposal Field (Specify Requirements =- _�-- - k r - - ------ ------------------- --------------------------------- - ------------------------ --- d r jA }. 1 ----- ------------------------------------_--------.------------------------- _------------------------------------------------------------------------__-____--------- ' r,.(Draw existing and required addition on reverse siclej +' I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County 5 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 becobI" to .Wor an's C mpensation laws of California." t . Signed = 4- Owner ------- -- --------=------Title-- -'41. t ----------- r - � ?-�,:_other- than'own�er) FCR DEPARTMEW USE QNLY ' - y APPLICATION ACCEPTED BY-:----------__ .- - - "=QATE---I- B--- DIVISION OF LAND NUMBER----------------------------=-- - - . _ DATE ' ADDITIONAL COMMENTS ----------------------------------------------------------- -------- - -- - ------------- --------------------------=-------- ---=-- ------------------- -- - - -- -- - -- Final Inspection by- ----------------- -- _ _ Date "----- :•� �-'Ex '3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &s 21677 R -746 3M