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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: {Complete in Triplicate) Permit No..-__7_7-_/ ' o mow.- . This Permit Expires 1 Year From Date Issued ti 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 Ordinancq. No.i549rand existing Rules and Regulations: JOB ADDRESS/LOCATION.__.,'5---;�+2•-5 - /J;Zv ---.---------------- ------------ --------- - --------- ---.CE Owner's Nanie`_.r '...`_'� L�---- --- .,.�.:.� NSUS TRACT Address ._ „544 P� Phone" �� a t - --- O : . f. ' C Contractors N _ ,r- 3 Nome--- --�t.,2� O��=� sem- -- iP--- ---- -- - --- --- T �, ., License`# —P ---Phone .54r Instollatio`ri will=serve: ' � Residence,. v '' " " -- -- F r _ „ ariment House.❑ Commercial`❑ =Trailer�Court ❑ rt ' -'e• v Motel ❑ Other ': Number of living: -units—, =-1:_ - _-_ omber-of.be_droomst Garbage Grinder__,._.___ Lot Size. a . i Water Supply: Public System and'name"___ :____ Character of soil to a depth of-3'feet: Sand ❑ Silt Cloy ` s ----.Privat { --- ---- - -- ------ '""�iF�ard ❑ y ❑ Peat Ej Sandy Loam ❑ Gay Loam ❑ p ❑ Adobe— Fill. Materia!_. s-._If es i Y , type j --=-------- '------- - { i (Plotplan, showing size of lot, location of system in relation to wells, buildings, etc. :must be placed on reverse side.) NEW INSTALLATION: '"' [Nofseptic tank�or seepage f '"""' a pit_permitted if public sewer is available within 200 feet,) 6 PACKAGE TREATMENT [ J SEPTIC TANKS[ ] ' Size __ _______ __ }... - ------------------ - -Liqu;d Depth-----' Capacity."__` �- TYPe ' , ' -- - { --- - Material- - --- ---No: Compartments----------=-- 5 I � " U� Distance to nearest:.Well.. / n ---` - ----- ---------- -_Foundatio LEACHING LINE tPro Line_-- -- --- -- [ .J No. of_Lin_es_: - - :_� Leh6th of each li�. _:_ -----' -- :---Total Length._-.-----'----------------------------y-03 � 1 ^ .D, $OX = :TYPe Filter Material--------------------Depth.Filter Material------------------- " Distance nearest: Well :_-- f ' "" l [,� - --- SEEPAGE SPIT ,. ....; __.. .-i -------- -------------------- p e. r Foundation � Property Lin _ [ J Depth. Diameter.'-- -` ------------------ Miter m --------------------- Rock F,lled ❑ [ Nu ber ' Water TablTabl b h"'_'"1""" "`•_- - f { � , :--------- --- - ock Size . --- -- # ------------------- Yes No ❑ iDistance-to nearest: Vilel _ d- tion-4------------=- - Prop. Line. REPAIR%ADDITION [Prev. Sanitation Permit# :_- ._.________ ---------- . F ,. ...---- --- -- �----Date-------- �---" ----- F - Septic Tdnk [Specify�RequirernentsJ " ------- -------------- ) ' - = = = ' Disposal Field (Specify Requirements){..-_ -_: s s f �� - ------ - --------------------------------------- k - -------------------- D ( raw existing and required addition on reverse side) 1 hereby certify that'l have prepared this application and that 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 a en signature;certifies the following: g .,I ts cern l � � l l fy-that' in the perfoinia�ce of;the work for which this permiVis� issued, `I shall not em to do i ) Jo become su p Y Y person in such manner as k f i to Wor n's bmpensation laws of California." Signed � y 4 BY-'------ -------'-----=- t - - - - -- TItleer.,_.. F If other than owner) FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY-_.___ -r," DIVISIONsOF LAND NUMBER. - 7 - '._ DATE- ADDITI NAL COMMENTS"- _. f -_.DATE.:_.- _ _. ---------------- -- - - - --- -- -- - - = 17 t oc. ---- 1 _ -- � � Q,�r - ---- -- ----------- -------- .----- "__--___"._""-__-. L Final,Insection by: - .. ------------- FH 13 24 -y� � Date - _"- .SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 2177 REV.7176 3M