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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.--- --1 = (Complete in Triplicate) -5 S, ,- �` Date Issued.--7770.7; --- -_ This Permit Expires 1 Year'Prom;Date Issued w 4 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-__56.423, ---- �'' e+�',- - ----------------------- ------- --------- -------.CENSUS TRACTr, - - 0��-/ Owner's Name (/m.... +C? F-- .--------- ------------------------------------------------------ Address -------------------------------- Phone }�- �/.-. ------------ �C/1.7�d.° ------------Zi Address ---��- -------- -------- -------- , - - ------------------ -----------------City- --- - P- -------------------- �2/ .3 •9%33 Contractor's Name.-(5-V1.-�� Com------------ �� J License #_- -- ----------Phone-------- --- Installation,will. serve: Residence4P'Apartmenf -Hou Commercial ❑ Trailer Court ❑ =. ... Motel ❑ Other = --�----------------- ------ <1_,`t of living units:___ Number of bedrooms X �_4-_Garbage Grinder-Grinder --:-Lot Size------------- - -- --- ---- ------------ Number �� Water Supply: Public System and name-.. Y. _.,_.. = Private ❑ Character of soil to-a depth of 3 feet: - Sand E] Silt❑ Clay E] Peat ElSandy Loam ElClay Loam [_1W i m Hardpan E] Adobe Fill Material--.-.:------If yes, type-------------- --------------- (Plot plan, showing sizebof 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 Size--------- ---------- -- Liquid Depth-- _.------ i -t Capacity----------- '-------Type------------`'---------Material_- - -------------No. y � Compartments----------------------------------- " Distaneto nearest: WeW-~ " '' -----Foundation ------ ------ProP Line--------------- y - i t'"" �" "n 9 Total Len . L1NE'.W`,[` ] No. of mes.. den th of each line. = - - _-. Length ------------------ LEACHING tBox------- - Type;Filter Ma erdal;-- -� Depth Filter=Mater.ial---------------------------------�:,s ----- --------- ' Dis pnc s — � e�to nearest;Well--------------��-_��ounda#ion--- �-- - -_-;�P-roperty-Line='"�� _---- -�--.-------'-. ' ' De thr'1 tk Rocl ,Fllled Yes No SEEPAGE PIT [ ] p Diameter Number : F�, �� 1i f 4 Roc Size -- = _ t,¢ •Water Table Depth f l Distance to nearest: Well- ------------------------------------------Foundation---------------------------Prop. Line----------------------- ' REPAIR/ADDITION (Prev:Sanitation,Permit# = Date----------------------------------------=----- ) y F SepticTank (Specify Requirements)----------- ------=----- / -----------------------------'----------- ------------------- ---------------------------------------- Z;, ----------------------- l 41 Disposal Field (Specify.Requirements) t -_-.- ----a:-.--------_--tea--- �- � �� " : -- ---------- - I - --------- ----- ------------------•---- ---------.,r.-----1----------------------------- ---- - - -- ----- ------------- ------ ------- ----- --------------- -------------------------'---- `------:----- -------------------------- ------ __ (Draw existing and required addition on reverse side) [ I• hereby certify that] 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: t� that the performance of the work for which this permit is issued, .1 shall not employ any ph manner as I certify ta in erson in suc, to become subject to Workman's Compensation laws of California." --------Owner _ 4 Signed- _ 1 ��. - T---- ------ TitleP BY -W- 4-we - M (If other than owner) r 'FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED 13Y' - - - DATE - DIVISION OF LAND NUMBER. --- --- ------------- --------------- DATE. - ::: ADDITIONAL COMMENTS-..------ ----------_- ---- - ---------------------•----------------------------------------- i -_ ---- - --- - --- ------------------ - - .Ik3 - � � ----- - - ---- - ------------------------------ --------- - - ------------Final -inspection by:.. Date ----- ------------- --- - --------- ------------------- -------------- ----- - --- -- -- EH Is 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV.