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TOR OFFICE USE. - FOR OFFICE USE- --------------------------------------------------------- SE: APPLICATION FOR SANITATION PERMIT --------------------- -- ---------- - - Permit No--.7f-,1,0Y- ----------- (Complete in Triplicate) ----------- -- -------------------- .Date Issued- � _._____.______ -Z--- -- ________________-._ This Permit Expires 1 Year From Date Issued Application is hereby made to the Son 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___ 7 - - r /�-- --------------------- - --=--------------------- ------ --.CENSUS TRACT---------- - � --� Owner`s Name. ` �� - Phone-------- ----- -. _5'. .1 Address--- :7 - Ot-4�� City Zip f- 1� ' Contractor's Name.-��. . --L -- ----- - y._s '�� _Phone--�XW`��0� -,- t-- ,-- -- ----�------- - --License #_ Instal lafion'wilI serve: Resi a ce Apartment House.❑ + Commercial ❑ Trailer Court ❑w otel 7.1 Other-. - -...I. {1 i 6 - r l9 Number of.living units:----:__.---_- Number of bedrooms_;5_. _-_Garbage Grinder_.-. ____i-_Lot,-Size;----------------- ._._..___._--_._-._- -i.-- p Water Sup y:,.Public System and name ` _... _ ---- -------Privat _ - '--- - Private Character of soil to a depth-of-3-feet:-�-Sand-❑"`"`-Slit"❑ Clo}TD Peat-❑"Sandy Loam Clay loam ❑ f .� t Hardpan ❑ Adobe ❑ Fill Material �____._If yes, type.--__.____i______---------------------------- 3 • � l (Plot plan, showi�jq size of lot, location of system in relation to.wells, buildings, etc.;must be placed on reverse side.) t NEW INSTALLATION: ,(No septic tank `or' seepage pit permitted if public sewer is ovailable'withiri 200 feet,) tom' uid PACKAGE TREATMENT Capac ty_�Z �K --. Material---=----------- ---------No: ComparlamentDept ! ' / , < / Distance to,nearest: Well-,__j��-----------------------------Foundation__'•1---- -------Prop. Line-se-------------- i LEACHING LINE"-!!["] *No �s-�.A . _ -.Length / 4 Total' Length._f _y_-_---_`.______:__'� of Lines_`.�� ___ �_____ __ Len th of eac line_ __ � -: _-- . D Box._-I._.---Type Filter Material;- __ __Depth Filter Material.- fJ __ _ _. i } Distance to nearest: Well"--------- =------------Foundation----------'-----------------Property Line--_--------------------------- SEEPAGE PIT [ ] I Depth-----------------Diameter-?---- -' ----_-_-,Number--------------------------------_ Rock Filled ,Yes❑ No ❑ f' Water Table,Depth---------------------------- - ---- -- Rock Size ------------------- Distance - -------- ----Distance to nearest::Well-- - "---- -- ---- --- Foundation . .-_-.---__-_Prop. Line----------------------------- REPAIR/ADDITION _..__--__________--- ---.REPAIIR/ADDITION (Prev. Sanitation Permit#-: ___-----:_-""^'"r-___,__--__-.- Date--------- _- ---_--------------- 1 Septic Tank (Specify Requirement- --------------------- ----------------::-_----_-_== . - =- = Disposal Field (Specify Requirements) ---- ---= _._- --- ---------------------------------- � -- -- --------- - --------- --------- ----------- --------------------- -------- - ----- ---------------- ---- ----------- - ----+-- --------------------------- --- ___ -_----'-------------`------------------------------------------ _ ---. _ _ - ---- ------e ---- rp �-^�--tri brew existing and required addition on reverse side) _- I hereby certify that I have prepared this application-and h t h 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: Y.. fa "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 become subject to Workman's Co ensation laws of California." Signeda .................. - . , ---- owner BY-1----------------------------------- ---------------- - --- ----- ----:------------. ----- Title----,-.--- 1 - - ----- ------------------- - ------- ---- -------- a E .. ._ R _ i f[ (If other than owner) t FOR REPATMENT USE ONLY APPLICATION ACCEPTED BY--- - - ------ --- -------- -- ----------------------=--------- .-DATE. --------------------- DIVISION OF LAND NUMBER: =------=--- - -------- - ='_..- , _---------.:_ :--------=-- ------DATE- ------------- i-- ---- --- --- - . '1 ,. y , ADDITIONAL COMMENTS ------------ ------------------=------= - ---------- ------ --------- ------------------------ ------------------------------ ------ -•--------------------------------------------------- ----------------------------------------------- -- - ----'----------------------------- ----- --- ---------------- ------------------ ------ - - - ----- ------------ -- -------------------------------------- ----------- -------------------------------- ----- ------ ---- ------=- Final Inspection-bW _.� - ----- ------�'" .Date------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7116 3m