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FSR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------------- Permit No.__��. (Complete in Triplicate) --------------------- ------- ---- 3-�� . Date Issued- 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/LOCAT N---- -I 3-7 -. ----------------- -----------------CENSUS TRACT- -------- -------- ----------- Owner's Name ^------<---------- - ------- ----- - - -------------------- --------------- ------------------- Phone --------� --------- r Z Address-------------------- -- 7�- r r—'r CitY �` .� Zip C� �d7 .... Contractor's Name - C �L.a/__----- -----------`------- License # _ Phone .. y A Installation will serve: Residence. Apartment House.❑ 4Crmnercial ❑ Trailer Court ❑ Motel ❑ Other----- --------------- =------- ---- ---------- `-,,Number of living units:-----------------Number.of,bedrooms_..==,------_-Garbage Grinder------------Lot Size--------------------------------------------------- -------- Water Supply: Public System-and name.-- - -----E----------------- ---- -----------`-------------- ---.- --------------- - -------------------- ----- -------- Privet . ❑ e Character of soil to a depth of 3 feet: Sand ❑ Silt❑_ Clay ❑ y Peat 0 t Sandy Loam ❑ Clay Loam ❑ Hardpan'[] Adobe❑ Fill Material............If yes, type--------------------------------- 'J {Plot plan, showing size of_Ibt;locatio1n 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 is available within 200 feet,) f--PACKAGE TREATMENT [ ] SEPTIC TANK [']} s :� Size-- ---------------------------------------------------------Liquid Depth--------------------------- CapacCa pagity: ity' --------------Type------`----------------Material--------= ---------------No. Compartments------------- --------------------- _a�Distance to nearest: Well.'- `--..____ Foundation. ....__ ...___.Prop. Line. LEACHING LINE. [ 'PLNo:of Lines.. Length of each line �Tstal Length.--._ -_ --__ -------- ,Qti" xi �.ry�{.�,v�--- ------------------------- j f :'TT'D' Box- -------_Type Filter Material------- ---------Depth Filter Material-_ - -------•------------------- S i Distances to nearest:Well>---�'-------___=.x`�_----Foundation-------f ------------------ Rock -- ' -------`Property Line-----------------------------------' ' a Rock Filled Yes No 4 SEEPAGE PIT ( ] - Depth----------------Diameter.---±----------r----Numb ❑ ❑ Water Table Depth r s _'A__.Rock Size- - ----------------- ------------------------- t Distance to nearest: Well-------------=------------------=----------`--.Foundation_ '------------.Prop. Line---------------.--•--------. ' ---) REPAIR/ADDITION (Prev. Sanitation Permit#------------------ -----------=---- Date------s_-._. -- --------------------------- - TT� - - Septic Tank (Specify Requirements] .=" Dis osal Field(Specify Re uirements)_.._._�--_.__ " P Y q -_---------- ------------------------------------------- i - . ------------ - - ------------ ------- ----------------------- ( aw 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 Regulations of the San Joaquin-Local. Hea.1th-District,.Home owner.or licensed agents signature certifies the fonowing.. " "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-------- -------------------- - ------ t - ---------- --- -,-Title-- ------- -------- ------------------------ --- --BY ( terhan owner) ! FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- .---- -- -- -- ------------------ -------------------------------------DATE.. ' DIVISION OF LAND NUMBER:_ -----------DATE-------------------- --------------- ------- ADDITIONAL" -- ---ADDITIONAL COMMENTS ----------------------------------------------------------- -------------------------------------------------------- --- ------- --------------- - ----------------------------------------- ----------------------- -------------------------------------- -------- ---- -- 'l� :-- - - - ----- -------------------=----------- ------ - ----- - -- - ---------- -------Final'Inspection b �` -.Date.-- EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 xfv., X ,aM �A , .