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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- 7/-/='3 ------------- (Complete in Triplicate) Permit No______ ________ _____ --- `'-�� Date Issued_o_�__�7" ?� .............-------- __-__._.--------.--------.-------- 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: 2 �%�� /r�a L.L. +410- TRACT- Owner's JOB ADDRESS/LOCATION. ----- --------1�--------------- -------------------------- ------------------ --- --- ------------.CENSUS TRACT- - -- - -- - --- - ----- �• Owner's Name----' - - - Phone-------------------� �� Address "/Z- - City - -' -----------Zip c� f Contractor's Name - - - - - -.License #_.Z `_� Phone_ =/- a '3 Installation will serve: ResidenceN Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ k Ot-her------------------------------------------------ Number --- --------------------------------------- Number of living units: of bedroams__-;)----.Garbage Grinder_/ //f _Lot Size----�-- --�------ ----- �S ---- --- --------------------------- Water ------ --------------- Water Supply: Public System and name---FL_R-4--c-- jqk------------------------------------------------------------------ ----------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe 0 l- _ ------------------------------ Fill Materia ._.-.__ -.If yes, type .- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) lfl NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ` PACKAGE TREATMENT [ ] SEPTIC TANK 41;1 Size_-__ X-_1r_---X- -T__.__ --------------------Liquid Depth._ W_y _____--6 CapacityloWe--------Type_<;CWC Cir :.Material�Founclation r!�__ rCV/__No. Compartments_______-__sem-------------------- Distance to nearest:Well ---_ o-47--r—.__--_-------_---®. ____.1(.0---------------Prop. Line---------5^__________----- LEACHING LINE [ ] No. of Lines_______ -----------------Length of each line. '' _"` __-_-____.Total Length --./,)0---_' ------ ------------ 'D' Box _________Type Filter Material ?oG1!'_-----_Depth Filter Material---- _----_-- -. __ _________ ________- ----_--_-I Distance to nearest: Well---W4WA_-----.-----Foundation-----------------------------Property Line_---------------------------------(b SEEPAGE PIT [ ] Depthcz ------Diameter--- -�------Number.__-__-.__ _____-__-_ --- Rock Filled Yes ❑ No,❑ l Water Table Depth-------------------- �--------------------------------Rock Size-------/z---------------- Distance to nearest: Well--------AOV ----------------------Foundation--------------------------Prop. Line------ ------------- REPAIR/ADDITION (Prev. Sanitation Permit#--__________________________---___.,.____-Date__________________---_--___-_.._--._-__-) SepticTank (Specify Requirements)------------------------- ------------------------...---------------------------------------------------------------------------------------- ------- Disposal Field(Specify Requirements)_.--------- -------- ------------------------------- -------------------- -------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ -------------------- -------------------- (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, 1 shall not employ any person in such manner as to beco f to Workman's C nsati laws of California." Signed--- ---------------------------- -------- -- ---- ----------------------------Owner By----------------- ------------------------------------------------- --- ------------------------------Title----------------------------------------- -------------------- (If other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - DATE. - /� ^ Al ------------------------ DIVISION --- ----------------- 'DIVISIO,N TOF LAND NU MBER- - ---,-- �' -o�"-- +-- - __r_. y_--.a -_ AD ITIO AL CO ENT - = a 2 - O Y�------ -7- -/ - 4y - --t'- -------- - ----------- -- -- T - ------ S�LL� ----------------------------- Final Inspection by - -- 1 ,� Date----'1793=17---- EH 13 24 SAN JOAQUIN LOCAL HEALT F85 21677 REVA/76 3M STRICT Op