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FOR OFFICE USE: _ FOR OFFICE USE: ---------------- -------------------- -------------- - - APPLICATION FOR SANITATION PERMIT Permit (Complete in Triplicate) ------------------------ ------- -- - Date Issued__�_ 0'_7,> ...----.-_--._______ __----------- -----------_-._ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local'Health-Oistrict for a permit to construct and install the work herein described. This application is made in compliancei �- C my Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION____�0_-- _ _ L2^ ___�rl ---------__ T C-------kio CENSUS TRACT.----'__________________________ Owner's Name----- C---- ----- -�--- ------------------------Phone--- _C"'lle Q 2 Address--------------/-- - - -City e. a - Zip------------------------------ Contractor's Name.. -Z7e4cn--------License #_o _ -__Phone_44KK__ ----- Installation will serve: ResidenceX Apartment House.❑ Commercial ❑ Trailer Court ❑ y Motel ❑ Other--------------------_ -- ------ Number of living units:___ +_--_____-Number of bedroom __--2Garbage Grinder------------Lot Size --------------- Water Supply: Public System and name________ _________________________C—_f*t--I_1.1-____ _ATE_l ------------ 4«-------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe Fill Material_.----------If yes,type______________________-____- . R (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 W'kth�*p 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAMCSize __ _ _. _--Liquid Depth---- ____ ------- Ca acity__1.2_C�-_ e___��-- MaterialC�" -----__No. Compartments___�_____________-______- p Yp .�+ _Foundation__ __ Distance to nearest: WellAN-0.9A------------------------ �� ------------Prop. Line----,l_to_: ---------zt LEACHING LINE No. of Lines--------I________ --------------------Len th 4elc line.----- __ L9---------------Total Length---------- _ 'D' Box________-._Type Filter Material -Depth Filter Material_____ __-___.________-_-______________________________Distance to nBarest: Well__A_!Q-� nda+tion____� ___/4 Property Line _.-__!___�__f--------------- SEEPAGE _ ___________ SEEPAGE PIT Depth_as7___Diameter :_ -6�__.Number_____t-__.___________________ Rock Filled YesX No __ -at�ctble_D!Rth.---- --- �-----------------------------------Rock Size - /--- --`� - 1 Distance to nearest: WeIL-__. ,�11_�__t L:�---____-_-_-_Foundation-----�Q--------Prop. Line--------------------------- REPAIR/ADDITION __ _______ _______-_REPAIR/ADDITION (Prev. Sanitation Permit#__________________________________________________Date---------------------------------------------- Septic ____________-_ ________----_Septic Tank (Specify Requirements)--------------------------__ -_ ------------------------------------------------------------------ Disposal Field (Specify Requirements)------ �.r�- ----------------------------------------- ------------- ------------- ------- ------------------------------------ ------------- - - - - ------------------------------ - ,(Draw existing and required addition on 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 of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to beco subj to s Compensation of C lifornia." Signed -1 1- -'� ,�.4-C-LI -- -- ----�- - - ------- By------------------------------- - - --------- - __o ----- ------- - - n - "—��--------Title--- -- � (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- - - Ay ---------------------------------------DATE.-- - �b ------------------- DIVISION OF LAND NUMBER -- DATE-------------- --- ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------- - -------------------------------- _- ------------------------ ° '------. 0 -' ----- ----' Final Inspection by:------ Fss 21677 REV. ��6 3M C r - Date --- -_�l ?_.7------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DIStl(C K CQ��