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FOR OFFICE USE-�� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- --- - - __ -------------- (Complete in Triplicate) Permit ---------------------I�-- Date Issued_//-1,SS�g .•-•----.__-__.___._____.-------------.--------------- 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.,5d9 and existing Rules and Regulations: JOB ADDRESS/LOCATION------------t: 72* 65- ____ --------fir+ku-_-r-----R®-------_ -------.CENSUS TRACT c------------------------------- Owner's - --------- --- ----- Owner's Name -- ��-i' -�---------------------------------------------- Phone �'J_ R 7 i /1 ,,q,, Address - - ; - - Ci G-- P Contractor's Name----------------_�� 1----------M� Jt _ I--------------------License #__- 2..4_T 7T-Phone--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------------- -------..-= ------ Number of livid -----Number of.bedrooms_Z------Garbage Grinder_ ---Lot Size-----------a_V---------/7- r_pS -_________ Water:Supply:_Public System and name--------------------------------.. .- - ---- ----•----- ------ -------- --------- --------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ " Silt E] Clay E] Peat'[] , Sandy Loam El Clay Loam ElN Hardpan ❑ Adobe ' .v. type`-------------------------------- (Plot - ---- ---------- -- -----(Plot plan, showing size of lot, location of system in relation to wells,bQ0404dngs, etc.'rhustbe 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.__ -._____ jg.X Y\4 Capacity ------- --- --T'Ype-----------------------Material---------` ---- `---No. Compartments--------- ------------------------- Distance ------- ----------Distance to nearest: Wel(-,.,,-----..,.:=-----------------------------Foundation--------------------------Prop. Line______...-_.-_.._______----� LEACHING LINE [ ] No. of Lines-----------------------------Length of each line-------------------------------Total Length.________-________________________ �p R,�` �'�� D' Box------------Type Fier Material__��th Filter MateriErC----------------------------------------------------------- '. Distance to nearest: Well______--~__________________Foundation____.---- ------Property Line____._.._-_______---- --- SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number--------------------------.----- Rock Filled Yes ❑ No❑ Water ,Table Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance-to -------- ------------ Distanceto nearest: Well_ ______________ -----------Foundation-------------- -----------Prop. Line__ ------------ ------------ REPAIR/ADDITION (Prev. Sanitation Permit#____._______________________.-`__--__.-_.___-__.Date_________________.______.______.._-____) SepticTank (Specify Requirements)----------------- -------- ------------------------------------------------------------------------------------------------- Disposal Field(Specify Requits) - --- . -- =— ---------tA-_e-.�\---- t '----- ------------ ----- ----------------------------------1 =` -- ---- ----------------------------------------------------------------------------------------------------------------- ------------------------------------------------ ----------- - - - - - - - ---- (Draw_existing and required addition on reverse side) I hereby certify that 1 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 ffie performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subj 7 t7�o��Work n Compensation laws of California." Signed.. ' =t -------------------Owner By--------------------�� -�/ A c7- Title [?1Q- _Y�/4- Q f' (If other than owner) oeo 45T DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------J4110*- -- - -- -- --------------------------------------DATE.---- - _j0 '----------- DIVISIONOF LAND NUMBER------------------------- ---- -------------------------------- -----------------------------------------DATE--------------------------------------------- ADDITIONALCOMMENTS-----------------------------