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FOR OFFICE USE: 4 FOR OFFICE USE: APPLICATION FOR SANITATION PEICMIT 7f-A'�� 4 ---------------------------------------------------- 'r Permit No............... (Complete in Triplicate) i --------------------------------------------------------- I _ .. ///3-7d tm Dae Issue ---------------- This Permit Expires 1 Year From Date Issued ii 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: . .� _ _ . � u ... .. ... tr.�.... JOB ADDRESS/LOCATION- f: '- -�------------------- .................. ...... -----t--CENSUS TRACT----------- .................... Owner's Name --- -wx--`k� �" " Phone- -�---J�� 4 m " 9 �36i .) Address--- ' ^ -- !t' - - -- - ---------------------------------------City_ ---- --------Zip-- --- r -/� --- License # r - Phone, .------`-�f- Contractors Name---------- __ -----.-��:Ll L -- tel : Apartment House. Commercial ❑ Trailer-Court, ❑ } Installation,will serve: Residence '�❑ +Other___._,_.___ - Y. r � s .: Number of.living units:___-�--------Number,of bedrooms..�____Garbage Grinder-.--_-3---:-Lot Size_":3®�_________________________ ___ -_�_-_ ,i Water Supply: Public System-and-name--------=------- I --------------------------- ----------------- ------------ Private Character of soil to a depth'of 3 feet: Sarid ❑ 1�Si1t❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 'Ha'rdp'a'n ❑ ` Adobe ❑i' -Fill Material___------ __If yes, type________________________________ [Plot plan, showing size of lot, location of system'in relation�to•wells, buildings, etc. must be placed on reverse side.] NEW INSTALLATION:' -AN'01-septic tank'or' seepage .pit permitted if public sewer is available within 200 feet,) (� PACKAGE TREATMENT- 1: _SEPTIC TANK .A -Size-------------------- Liquid Depth. __�_ Capacity-----=------=-----=--Type--------------=-------Material------=---------- ,. -------No. Compartments.- ---- ------ --------------t - Distance:to nearest- Wel l:._;_--------------•-- -----,Foundation--------------------- Prop.FLine---------------•------- t_.-' LEACHING LINE [ ] No. 'of.Lines_° --- ;---------------Length of each line I - Total Length. --------------------------- D' -:-"-"---"---- -----------D' Box---------- Type Filter�.Moterial-------- ;____Depth.filter I �! ' . { Material__"-_-_._r---__-- _.k - ----------- Distances _- Distance to nearest: Well`"--- ------------------Foundation }_--- -- _._..Propert Line --- ----- - ----- No--- �C � ❑ NoSEEPAGE PIT Qepth;_. Diameter --__Number-------------------------------- - Rock Filed ' Yes ❑ •is � Water!TbleDepth - ---------- _ —_°"-_�_ -�------- Size_ le --------".---_-".--_.--r __�. _ ------------- Distance __ --- Distance to nearest. Well'_______ ______ _-____-------------------------- - Line------ - -- --- REPAIR/ADDITION (Prev. Sanitation Permit#-"-.--'°------------------=-`----_-------- --,--=.Date---------------------- Septic Tank (Specify Requirements)."-"_'_.- 'i- r__ � � Disposal Field(Specify.Requirements)__: -_ f-�_ - __________________. ---- -------------------------- e --" - ----------- -- ------- ------- 3 S- - 1 =_ ----: t_.(Draw a isting and required addition-on reverse side)-r- k I hereby certify thai fFhave prepared thit 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: . "I certify that in the performpnce of the work for which this permit is issued,.I shall not employ any person in such manner as to beco s bi t.to W kma s Compensation-laws of California." 1 Signed = it -Owner _ _J By-124. --------------------------------------- ' : -----------.-Title -----4- 1 --+------------------------------ ------------ (if other than owner) " ` i IIVFOR/DEPARTMENT,USE QNLYP, APPLICATION ACCEPTED BY_..- ..: �� - - -- '-------------- DATE. f Z ' DIVISION OF LAND NUMBER---------------------------------�; ------------------DATE---- - ----- ------ -- ------- ---- -------- 7 � , - f - ADDITIONAL COMMENTS- --- ----- --:---------------------�-- -- ------------ --- ---- - ----- -- !( f -------------------------- fu ----------------- -- v ------------------------------ ----- ---------------- ----- - } Final Inspection-bY: -- - ---- "_."'�.` � .� ... Date--- --- ---- x EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s,21677 REv. �n6 3M t