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m. FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- - (/I-- Permit No.--7,7 _yFS (Complete in Triplicate) --------------- --- - ----- ----- �' Date Issued-��_ ___._ � ----------------_--------------_ ________..._.__ 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 0 d a No. 549 an existing Rules and Regulations: JOB ADDRESS/LOCATION----AIJA— s- --------------- ----------r444- -------------------CENSUS TRACT-------------------- Name---------- - - ------- c. .. "'------- ------------------------------------------------- ----------Phone------------------------------------- Address------ - - ------ --------------------- -- ---City---------- ---------------------------------Zip----------------- - Contractor's Name---- ----- -- --- - __ ---------------------------------License #- -V7/______Phone____9.3J Q-_ - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El Motel ❑ Other -------------------------- ---------------- / y Number of living units:-------�-------Number of bedrooms_-____Garbage Grinder------------Lot Size----� ___________ i.� Water Supply: Public System and name-------- ---------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: $and-fl ---Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] tc Size___�4---A ,!_�V-f�--------------------------Liquid Depth-_'�_____________--__Capacity--1-_� D---Type-- . - aerial--- - ----No. Compartments----�-------------------- Distance to nearest: Well_-__-- -----------"-- _ L - P ______Foundation____/- Q______.____.--Pro Liinnee----�_!________-__ LEACHING LINE [ ] No. of Lines___-_ _ -_-____Length of each line_______�� _________Total Length -__-/_L_l/_______________--._-- � s 'D' Box-----/_____Type Filter Material___._ ___ ___-Depth Filter Material-------/-�------------------------------------------- - Distance to nearest: W6,11------ - Property Line ----------- " SEEPAGE PIT [ ] Depth-_1A__S7._Diameter, - -----------Number-----19- -------------------- Rock Filled Yes No ❑ Water Table Depth-_,"' -------- -r Rock Size---------- ----/ --------------------------- --------------- Distance to nearest: Well___-_/; ._-._______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: "1 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 become subject to Workman's Compensation laws'-of Catiforffia. 'I Signed-------- = ------ - ----- ---- ---- ----Owner BY - ` ]� > -- - ---- - ------------- Title. ttt777�"_��111 (If of er Ln owner) "_ FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--- ----- --- ----------------------------------- --------------------------------DATE --------- DIVISIONOF LAND NUMBER-------------------------------------------- -------------------------------------------- ------------.DATE--------------- -------------- .. ADDITIONALCOMMENTS----------=--------------- ------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ --------------------------------------------------------------I----------------------------------------------------- -----------I------------------------------------------- - ----------------------------- - ,, ,- -------------------------------- ------ f ;, FinalInspection by:---4----------------- - '_ ------------- --------- ---- ----- --Date----------------------------- ------------------- EH -- - ------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 776 3M