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FOR OFFICE USE: U ; APPLICATION FOR SANITATION PERMITFOR OFFICE USE; ------------------------------------------ --- --------- (Complete in Triplicate) Permit No._7_ -_-7/-� A ----------------- 14-N11I- ------------------------ !�Y � i -Date lssued__��.�.-5._:�� ---------------------------------------_-__.______.__ 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/LOCATION. Q;--- ----- ---------------------------------- - ._CENSUS TRACT ' Owner's Name---------- ----- --b /d- ------------ - ------------------Phone./-Z-- -/ t Address - -- �4 C . '� - ' --- ------------------City---- - - ------z1p-- -------------------- x Contractor's Name-.--------'__-'-- '_-.- --- '-- -- ------------- ----License # .5 - ----Phone_. {�-fP_ f_. -Q- ' *�� -;- Installation`will serve: ? Residence � Apartment House.0 Commercial ❑ Trailer Court ❑ Motel-�*Other---------------------------------------- ---.- um er o living units_________________ ume ar a e Grin er_._______�_Lot.Size______ pp Y _ Water 5u I Public S stem�and'nam _ --- Private ( € et: . Sand Silt ''Clay ❑ . Peat _ ,, Sandy Loam [] Clay Loam ❑ , Character of soil to a de th of-3;fe Hardpan ❑ Adobe Fill Material.-_`_ �"-•_.If yes, type-.--.--.______________________ an ,�L/�y�/, - .-- 2 (Plot plan, showing size of lot, location of system i,n relation to wells, building etc,;must be:pl.aced on,reverse side.) INSTALLATION-— [N,ok septec,'jank or'�seepage pit permitted if public sewer is available within-200 feet,) � _ _ _- __-______._.____ -riu 'DPACKAGE?TREATMENT SEPTIC TANK Size- ep`th`_ - ! '_-_ _ No. Compartment -__ -_ ;,r Type ----------Material Capacity.146 ' - W . 11 Distance to nearest: .Wel l.._ d -Foundation LEACHING LINE ! No.,of Lines_?--____- ------I_____:Length�of each line..____. ]---------------„Total Length.._ _ ------------------------ D' Box ._rl_Type Filter Material /(�f ,___.Depth Filter Material ' ___.__.____._ ___._ r_ L. 'Distance;to nearest: Well_°___ ,�d_{'rye___ Foundation -___ l+ �f ---.Property Line------------------------ __Z�x--.Diarrlefee'y_ .� , .. .� ' r,y,,:u SEEPAGE PIT Depth. umber_ ” Rock Filled Yes No ❑ Water Table.iDepth---- - -------------------------RRock-S12e Distance,to-nearest WeIL /'" ��__-_Foundation._.___.r�__' op. Line__€f"i" -------- --- ' i REPAIR/ADDITION (Prev. Sanitation•Permit#--.---__.7��_- -----:-----'--------------D'ate--- -- -7 --_--- ) I Septic Tank (SpecifyRequirements).-.-------L------------ -------- --------=--------= ---- ----=---_-_----------- ----------------- --------------------------- Disposal -------------- --- --Disposal Field (Specify Requirements)------------------- '- ------------------------------------ ---------i3----------------------------------------------------- --------- ---- - ---------------- ---------------- ----------------- ----------------------------- ---- -------------------•--- ----- '--- -------------------- --------------- -------------------------------------------- -(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 Regula_tions 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." ` Signed-------- ---------------------- - -- .Owner —A BY- ----------- ` "L -- .-'k-- ' e - `: - Title-- ------------------------------------------ - ri other than owner) FOR,DEPARTMENT USE ONLY *. APPLICATION ACCEPTED BY_______ ____ _ _ __ - --Ave DATE._.__: a, � DIVISION OF LAND NUMBER - -------------`----------------------------------------- - DATE -- - - -- --. ADDITIONAL COMMENTS-------------------------=' --------------------' - ---- ------------------------------------------------- {=- ; ' ( 1 --------------------- ---------------------- - - ---- ._ --------�---------------- ------ ------------------:------------------------------------------ �.:. - ------- - - --- - - - �� --- - Final Inspection by. �,.�., ... ...- -_.-.-.-- �--- - ------------------------ ----Date.--- ---------------------- -•-•'-. -'-- 1. ----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/16 3M