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FOR OFFICE USE. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No____________________ _ ✓ 11 Date Issued__/--7g5-_.7/ r •-- -------------"---.-.--__._____.__._-__-_.____:___-__ 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/COCATIO -` -------------------------------- - - - ----.CENSUS TRACT..---- ---- ----- .. Owner's Name--- ' $; t ----------------- // - --:- .. ---- - - -- � Phone Address--- aO ,_. .. ---------- - .--- ��l -` city, - zip Contractor's Name ----- - --------License #_ _ ��_ Pl one--------------------------------- r C r�� 1- ' Installation wily serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ r -Motel ❑ - "Other__. f = ,€ 7. ; Number of living units:------ _____Number of bedrooms_:_,7__-.__=.Garbage Grindar_'f_,.:_._ Lot,Size______ _ __._ _f ---------------- Water ._ --.-.Water Supply: Public System'and name-----------= -- -:: �:'- --------- ------------------ r'� Private Character of soil to a depth of 3 feet: Sand ❑ Silt LjClay ❑ " Peat ❑. SandyfLoam ❑ Clay Loam ❑ � Hardpan ❑ Adobe Fill Material_..__'.......If yes, typ'e� 1.rT------------------_- ¢ (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 .pit permitted if public sewer is available within 200 feet, PACKAGE TREATMENT ['] '-SEPTIC TANK J.] Size------------��"-----`�------/----------------- ----Liquid Depth-,_ ----- -""-- 6 Capacity---- --.---------'---;Type--------------------.-_MateriaC `y-- t_:-:--__No. Compartments---------"`' Distance.to nearest:.Well-!--- -.£:_'Foundation.---= =------'------- Prop. Line- -------------------------- I LEACHING LINE [ ] No. of Lines--:-------- Length of each line------------i �_--.Total Lergth - ------- y = 'D' Box__ _---_,__Type Filter Material --.-----Depth FilterMaterial- ------------------___ __ Distanc&to nearest: Well_? _ _'__ __Foundation '___.Property fine-_.-_ t w . .... .. . .:._ _ _ . __oc . -- er--- k Filled Yes=---------------------------- RocE] ---No E]SEEPAGE PIT I 1 Water TableDe ' Dthmeter---------�-" -�-"-"Numb - .. _ _'. '^ Depth-- p Rock Size--- = ----------------------- I Distance'to nearest-`We11 -._` -:' "`y___._____________________;- Foundation_______"._.___`_ Prop. Line___________'__-___ ' REPAIR/ADDITION-(Prev,'Sa`nitation,'Perrriit-#_____________________ ----_-.Date--------: ---------- R ` Septic Tank {Specify Requirements)-- ` ---- -' ---- -- - ' � =` { -� Disposal Field{specify Regdirementsl-- =+' +� ------ : -- 1 --' ---- - -------------------------------- -- r: ---- . ------------------------------ _________ ___k ------ y d ` (D aw existing and required addition on reverse sided ¢ I hereby certify chat 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 Health District, Home owner or licensed agents signature certifies the following: ' . certify tha—h theperf ro mance oF-the'twork for which this permit is issued, I shall riot employ any person in such manner as to becomUsbict to Warmans Compensation laws of .California." ({Signed-- - ----=---- wner %__ - i ._ $Y ! / Title---- --- Y --------------------------------------- -- --------------------- - - (If other than o er) 3 FOR DEPARTMENT USE ONLY: APPLICATION ACCEPTED 13Y---- - - --------------------------- ------DATE. a--Z-14---- 7------------------- DIVISION -- - ------ DIVISION OF LAND NUMBER ------------------- -------------------------------- ---- --------------------------------------- -DATE.- ----------------- ADDITIONAL COMMENTS --_-_ j _--_.___.-_ ~ ------------ -----'---------------------------- --- ----- --- -----------==----------------------- ------------------------------------------------------- --------- -- -- k. --- -- ---------- = ------------------------------ - _ Final Inspection by:._ /��.""` `L ��C -------- ----„r�---- - ---- Date' �✓ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M'