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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------- ----- (Complete in Triplicate) Permit ----------------------------------------------- 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION--------------_ _ _, Y-_ _ ,.,__ - CENSUS TRACT______ _ -- -- Owner's Name--- ! ------ -------- -------- ---- ------ - -- --------- --------�----------------------Phonej0_ _ .-- -c- -- 2 Address--------------__�-•�t--�"�`------------------- -------- -----------------------------------------City--�- ---�'-5--�--------T-- -------Zip------------�----------- f �'�' Contractor's Name-----�-,,, --/----`-�_Z _ . C----•--- ---------------------------License #�l_�j Phone �=�-/"' - Installation will serve: Residence Apartment House❑ Comrnerci y Trai4&r Court. ❑ f0tel ❑ Other-------I----------------i--------------------- age -------_ --- --- Number of living units:--- ----------- of bedrooms _____Garbage Grinder._______L�t Size_________----�-----_______-_______.__.____--- Water Supply: Public System and name______ �______ ------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay [1] Peat[j dandy Loam' Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material_-_....-_-_If ye , typie_______#------i-:,___ (Plot plpn, showing size of lot, location of system in relation to wells, buildi gis-, etc. m st beplaced oin reverse side.) NEW 114STALLATION: (No septic tank or seepage pit perrKittied if public sealer is +aiJdh le withii 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Si`f'Es :-_____________ _- _------------------Liquid Depth ---- ----------- Capacity---------------------Type----------------------Material--- -----------------I----No. Compartments----------------------------------- Distance to nearest: Well----------------------- - ---- ------- Line---------------------------- LEACHING LINE [ ] No. of Lines___ __________ _ ___---_Length of each j.......-.�.._r-------Total Le th---------------------------------------- 'D' ____ ------- - ------ ----------'D' Box------------Type Filter Material-------------- Depth Fi-Iter Material----------------I--------------------------------------------Distance to nearest: Well----------------------------Foundation. _;-------------------------Property Line__________---_--__---________---: Diameter --Number ' Rock Filled Yes No SEEPAC,E PIT [ ] Depth ----- - ❑ - Water Table Depth------ - !_ -------- --------_.,-----_ __1_ -f------- Size---------------------- ------------------------- BiStance=,to nearest: Well ___ ,f `',@undation Prop. Line--------------------------- J . REPAIRADDITI(?N (Prev. Sanitation Permit#_ __ - t- _ a_---_ ;------ _:[Sdte--------------------- ��__' ______ ---1 Septic ;ank (Specify Requirement4) � '•' - -- ' pp -- t DispospI Fieliily iC Y'l� u' gnts)_1 -tr--- � Y ff ,e ` s t ------------------- ----- -------- -------- ------------------------ - --- (Draw existg and requ red addition 9 reverse side) I hereby certify hma i 1 W F111pa red this applicat na- dome+in accordande with San Joaquin County Ordinances, State Laws, and Rules and Regula> ons of the San Joaquin Local Health District, Hoppe owner or licensed agents signature certifies the following: 3 "I certify that iVthhe rformance of the work for which this permit is iseh I shallt employ ay person in such manner as to become man's mpensation laws of California.Signe - ------- Owner By----- ---------------------------------------- -----=-- ------------- ------Title-------------------------- (If other than owner) FOR DEPART NT USE ONLY APPLICATION ACCEPTED BY-- - -- -- -- --- -- --- ----- ------------------------------------------------DATE-L -F7 7d------------------ DIVIS16N --- -- DIVIS16N OF LAND NUMBER--- --- ------- -----DATE ------------------------------ - - ------ - -- ADDIfiiONLC /NMENTS -------------- ------------------------------------------------- ---- -- --- ---- ----- ------ --- ------ -- --------------- ----------- ----- -------- --- --------------------------- - --- ---- ------- ------ ------------- ---------------------------------------------- / ------------------------------------------------------------------------ ----------------------r------ _ i______________________________s ---------- -----:--- -- - ---- ---._ I -----------------------------------------------'-_ ---_ _- ____- __-----__________- --_--____-----------------------------------------------------------------'-i.� -_ _ -. -_---_-_-------- Final Inspection by:------ - ---------------------------- ----------- ------------------ Date-' -_� -------------------- EH 13 24 SAN J QUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/7d,ann