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FOR OFFICE USE: s FOR OFFICE USE.. APPLICATION FOR SANITATION PERMIT �j � :� _ � _ [Complete in Triplicate) Permit No.`--- This Permit Expires 1 Year From Date Issued Date Issued__ ..'2_�'_ ____ _____________________________________________________ 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 eyisting'Rules and Regulations: JOB ADDRESS/LO, TIO ._-_. (� � �- --r._------ °---------_..CENSUS TRACT----------------------........... it _ 7 ti i t r--Owner's Name t --- - --------------- �; - Phone Address.../-� -Q ..% -? Ili -c-_-` GY '.`'z?"(.�"' Z,if? Contractor�s�-Name_ �_ u �_ .: .__. #-� � _1. _ Phone _ ._t1'._ `` �1 _. /. _I r G; License --_-- installation-will servg, Residence�e'—Apar#ment House❑"""Cammercial ❑�"Tra ler Court,0 ` Motel ❑ =Other bedrooms__.= __G,arbage Grinder..___.__.__Lot Size____. __ _---------------------------------------------- 'Numberfesf Water Supply: Public System and name- _ x., �- o livingunits:_ -_ ;___.._ um er,o y -------- ------------------------------- Private haracter of soil to d depth of 3 feet; Sand❑ Silt❑ Clay ❑ Peat ® Sandy Loam Clay Loam ❑ Hardpan ❑ Adob�� Fill Material,--_-'------If Y4s, type-------------------------------- (Plot --- --- --------•--------------(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 of seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT Ca ac t PTI STAN Ij ] ' fSi e-------IX-- ,_- - ---------------Liquid Depth-_-V------------------ P Y�L _Type:tl%n _:...Maternal:. ��---------=-----==No.1Compar#menu--:/ -------------------- . �. it � i Distance to nearest: Well._..... . _r------------------ �_:Fo'undation Y_� - Prop. Line_- _- t �/-c LEACHING LINE [ } No. of Lines.____.. / ______________Len th of each line,_ . Yp . .. g �- �_ -,-------- =====r== Total Length._.��- �``� _- � _ D' Box--.-;� _ _T Typefilter Materia ' -.- -- epth Filter Material .�g ---------.----____-- - -_ Distance to r�earest:'Well^� � _ ___:Foundation.__ `-_ '____ -,---property Line _LL 1.__ Diameter: r T j ] Depth- 1 ._ Number i R Filed -Y No Distance to nearest. Well_. ___ .___ _-_-.-___ _Foundaf olrie_ Water Table Depth._.:. __ r -- -----------------Prop. Line - REPAIR/ADDITION (Prev. Sanitation Permit_#...r_.___. ---------------------------L- oDate.._.__.: -------------------------_______-----}- Septic Tank (Specify Requirements)---- — r �__ _. �_.= - - - ' __ --- Disposal Field (Specify.Requirements)------------ -- - --------------------------------------- - ------ ---- ---------------- --- ---- ------------------------------ -------- --------------------=------------ I------ ----- -1-.`--------------- -------------------------- --------------------------- --- ------ -- ----- - --- - -,--- ---- --------------------------- ----- --- ---- ----------- i t (Draw existing and required addition on reverse side) I hereby certify that-1 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-rL-ocal Health District, Home owner or licensed agents signature certifies the following- "I certifythat in the erformance of:the work for this er mit is issu ,,`I shell not employ any person in .such manner as p P to became s/ufbj rk bn's Com ws of California.',./Signed - -- - -------._. Owner [ � t �� BY- ------------- ----- - ----Title 1 � (If of r than owner[ FgrRDEJARTMENT USE ONLY! ' APPLICATION ACCEPTED BY------- = !``` --------------------------------------------DATE._'----- /_ __�_d/_77 DIVISION OF LAND NUMBER.-.____: ----------------------- _� ------------- - - - � --- - DATE-------------------------------------- ----- -- ADDITIONALCOMMENTS------- ------------------------ - -----------------------•------------------------------ ---------------------------- -- --------------- ----------- - -------------------------- ------------------------------=-=- ------ ----------------------------- �------------------------ ------=---------------------- ------------------------------------ _ x ----------------------------------- --- ------- -----'--------------------------------------------------------------------------------- ------ ------------------------------ ------ -- --- . ------ --- - ------ - _. _ ... _ __ _ _.. Final Inspection by:__:- - --- Date------( --�� --- EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M 4