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{ FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT :tet 1.� -------------------------------- (Complete in Triplicate) ,,�x ''Wii�wieramit No._7 7_ .3 a#e�l stied - - -----------------------------'------------------------ This Permit Expires 1 Year From Date Issued sr;A g,� iot 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: i JOB ADDRESS/L TION. f11.� ----------- ...... ` '�' T= -----CENSUS TRACT--------------- --•--------- Owner's Nam = - ---------------Phone---- `----- --------- - --------= --------- --------------- ---------------- .. w . • 4 w - - '� Address- -- ---- �'L : -- -- --- ------- --- - = ----- --------------- ----- City --------------------------Zip --- ---------- --- ---- Contractor's Name �:.�s.- rr c-; {--�� -- -License '# �� Phone -------------- ---`-- ---------- ---------------- -------- Installationawill serve: Residence E( Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other '--------------- Number ------- --=Number of living units:_. ; ____.______Idumber of bedrooms---3----Garbage Grinder...'---------Lot;Size_.._____________________ _ ___ ---__..-_ Water Supply: Public System and name----- --- ------- ----------------------.,-.--------------------------------------------------___ __---__:__ :. -: ------ Private Character of soil to a depth of 3 feet: Sand [D .Silt❑ Clay ❑ Peat EJ Sandy Loam E] Clay Loam 0� s Hardpan [] Adobe E] Fill Material_ ----- --If yes, type---------- --------------------- f (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 ( ] SEPT' IC TANK [ Size_T� �_ _ -____:r: _______ s ----------------------Liquid Depth.: -V - -- -r-- t Capacity__1: _-______ Type=' Material.,A_.' __-.-No. Compartments_.__?"----- ---------- _ i Distance to nearest: Well-,.—_- �--__,._ -------___________________Foundot.ion______.�._C_��_____Prop. Li nes._�~�___.____i_ . 4rl�FrL _r o I LEACHING LINE (_ No of Lines________ _________°__._____..length;of each line, ` _Total Length.._.__�__a_°_ '_._._____. .. - . r ' I 1 K; - t� ter Material-- ----I---`�- ---- -- -foundation_-- D' Box_._---------Type`�ilter Material" _--- -------- epth Filter _ �- � . Distanceto nearest`WeIL'________-S o_ I'__.___l_P_J- .__.Property Line ____ ---------- SEEPAGE PIT ( ble ttD��eDthrcief r-- -- -------Number---------->-3- ' Rock Filled. Yes.�No p ! ` p irk- Rock Size �1�._r• ----------------------------- Water - .. L �. ----- ---._Foundation--------1--d--1 --Prop. Line----`� �--------- ( Distancerto nearest W.�I-t;,r.__._'__.�i___ � REPAIR/ADDITION {Prey: Sanitation Permit#...... ..... __- -:--:-:-- Date j,�.= Septic Tank (Specify.Requirements)---------------------------- ---- = = ==- '"�� Disposal Field (Specify Requirements)--------------=----.-.-:,-------- --------------------------- ----------------------------------- - ------------------------------------------------------------= =----- ---- ------- ------ q - - ---- ------------'---------------- -------------------------- ----------- (Draw existingand 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 peiformance'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.-California." I t Signed----- --------------- -- -- r .._. _. , r� 4 Own. .. .�/ _-�/I ---- Title (If other than`owner). : . . '. .: . ..i p... I. . _ .. .. 'FOR DEPARTMENT USE ONLY'' "�! APPLICATION ACCEPTED BY 11 - -- = DATE.-, DIVISION OF LAND NUMBER._ ----- ------- -------------- DATE.------------------=---- ------------------ --- ADDITIONALCOMMENTS------------------ --------- -------------------------------------------------------- ------------ ----- ------------ --=-------------------i------ --- -------------------------------- =------------ --- ------- ----------------- --------------------------=------------------------------------------------------------ -------------------------------- f ---------------------------------- Y = - = ---------------------------- -- -- -- ------- - Final Inspection by: _ = ---- ---- -- -- ----------------Date:-- '----- �y EH 13 24 SAN JOAQUfN LOCAL HEALTH DISTRICT Fas 21677 REV. 7176 3M,.