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.: �R OFFICE USE:. -- ' APPLICATION FOR SANITATION PERMIT FOR OFFICE.,USE: ----------------\ - 17_� (Complete in Triplicate) Permit No._' .. Date Issued__.___'". _... •------------ - --------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per mit to'construct iand..install the work herein described. This�application is made in compliance with County Ordinance No. 549 and existing kules and Regulations: j JOB ADDRESS/LOCATION__ ---- - - - - r--- ----------------•- TRACT ----------------------- ------- - Owner's Name-------- - '-- - Phone --- -------------- Address- -----=------- _ 6 ,. ; �� > - = -- - --------------- --- ----Zip ------------- Lic rase Contractor's Name-' �' ----------------------- -___Phone-_ . ___- r j P.. # Trail � � 1 Installation.will serve: Residence A artment House.❑ Commercial ❑ Trailer Court: ❑ ['w f Mo e! ❑ Other--------- = ' Number of.living units:__---./:-----_Number of • ► bedrooGrinesfr � Lot;. Size______. _ p --------------------------------- Water SuPP-1Y_.Public System and name -`4=- 0 -------------- --------Private ❑ Character of soil to a depth of 3 feat: San Silt❑ Clay ❑ Peat ❑ 'Sandy Loam ❑ -Clay Loam Hardpan ❑ Adobe❑ Fill Materia,l__..._..____If yes, type_.___- - - -__._ ' t - [ .i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.'tmust be,placed on reverse side.) l� NEW IN (No septic tank or .seepage'pit permitted if public sewer is available within 200 feet,) -> .- PACKAGE TREATMENT [ ] ' SEPTIC TANK ' f p ' t; [ ;].. - Size---41 y) --- = - --------Liquid Depth � � ---°--- F,.. Capacity yP -=�-_-: m artments. - -- --------' z P � • 'T e.__ M terial___t g No: Co , Distance to nearest:P, Well _ _ `' .fig Length of.each lin®._ Found d�__.___ '��al-•-----s- Prop. Line.-_ y,`�----------� ' r _ _ e� LEACHING LINE; ( ] No. of Lines_ :-_. - -. I h . Len t ---" D' Box .Type Filter.•yMat'erial C_,rdafi6n__"0_A De tfi Fitter*Material ' .__--_DistancE>to nearest: WeII :_ .� __ _-. --..Property Line----------------------------------- T [ ] Dept'' e - is eter .X ld�` Numl�er""s_ ------- ¢ s R filled Yes ❑ No❑ 4 IA. � � r ` i r f Water Table iDe`th� .- I. _ .f _ - - _ � � p: �- - b ---Rack Size: ------ �=-- ------------------- 'Well. ---- - ---------- Distance to nearesf:',Nell._._ _ - ---Foundation ?--------- Prop. Line--- -- ----------_----. REPAIR/ADDITION (Prey.Sanitation Permit# -.__- --' `, ' pate :: -------------------------- 1 Septic Tank (Specify Requirements).--____________. .�-__ - - Disposal Field (Specify Requirements)_______ ___ _______ _ _ __ 4 1 -- ----------- -------- t 9 o 6rawexistin andrequired addition n 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 oi:'the San Joaqui.nC Local Health District, Home owner or licensed agents . s - si nature certifies h s g s t e following: "I certifythat in the . �y �� "��--.� per#ormance of'the jwork for hick this'p�ermit is' issued; I shall not employ any person in such manner as ro become "subject, to.Workman's Compensation lIt aws of California." ;' 4 t Signed---- 7t� i"'- _ ---= $Y x l - --- - ------ ----:� --Crwner - - - - - -- --- --- -Tit e.�, r {fof er than owner) �N TV FOM DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY.._--------1.11V_ DIVISION OF LAND NUMBER;------- -------- -- v---4 t _. 1�=• � - - `� _ITIONAL COMMENTS.--- -----DATE,: AD- _t_________________._____ ___.___.._-_. ___.__ ...__.._-.__.. r -"____________________________---------------------_--------- f -------- -------------------------- '_ - ------------------ = = --------- - -------------------- } Final Inspection,by:---- __ =' ------------------" = - Date_.__ -- ---- F EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV.7/ , �I