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FOR OFFICE USE: V/APPLICATION FOR f SANITATION PERMIT FOR OFFICE USE: (Complete in,Triplicate) Permit No, -^ D, ti This Permit Expires 1 Year,Front}Date Issued Date Issued_ _D..-=l&-r � -----/--,�--�/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. F This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N_/. - ._-.-_-_-__ . - -- ------------- -- .,:----- --.CENSUS TRACT Owner's Name = ---- ------ --------- Phone- .- City-- ~ ---------------------------zip Y � v -------- --- Contractor's Name , � ---�,�,-_ License #._. _a' Installation will serve:,,,,,.. Residence Apartment House E) Commercial ❑ Trailer. Court ,0 4.�. . ,. Motel ❑; Other----------- -------------- - ------------ 4.11 Number.of living units:_____.-_'!__Number.of bedrooms-_-__.__.Garbage Grinder-._..__--__L4. 4 Size.__.. ...-_-° -- I - , E , — ------------------ -- Walter Supply: Public System and"name r-------------------------------- ----------=------------------------------------ -- Private Character of soil to a depth of 3 feet.-. - Sand j] Silt ❑ Clay ❑ Peat❑ Sandy Loam lay Loam 0 Hardpan ❑ /Adobe ❑ Fill Material.......------lf 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 availablewithin 200 feet,) PACKAGE TREATMENT i [ ]', SEPTICTANK ' Size-.-- -IS-------- ------- -- --------Liquid Depth---------------- s: t `Capacity -- ? -------Material------ :..No . Compartments--------- ------ Distance'to nearest, Well -____,,.___ ------------------ _ -- --- _„-_----- oundation • ---------P p La ne _------ ---I _-_ LEACHING c LINEi [ ] No. of Lines------- alength of each line _ Total Length________ [ D' Box------------Type Filter Material `r `Depth Filter Material t f "j :.. ------ ! Distance to nearest: Well------:-_---/-- -.-----Foundation---- ------------------Property Line-------------- ------------- SEEPAGE PIT [ ] Depth________________Diameter -_-__._- `_ - -I------_ Rock Filled Yes ❑ No ❑y�; - Number .. t ._. . ; Water Table Depth--------- ----= .-- Rock Size-------`---------------------------------------- t Distance to nearest:Well ?_ _`__..__ ”„---------_-_Foundation--___.__ _ `_ Prop. Line_______- -_. REPAIR/ADDITION (Prey:Sanitation Permit#-:t.-- :_-__:----.=x ;----- ---- Date--.---------=----- ----- --- - -----------1 � Septic Tank (Specify Requirements)----------- ------ ----- } ---------------------. _: -: '_ Disposal Field (Specify Requirements)-------- :_ = v� ' _- ---------------------- '-------------- _ - L------------------ --..---- -----Draw ex3stin and re uired'addi � .----- - ( g l q tion on reverse side} R 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 performance of'the work'for which this permit`is issued, I shall not employ any person in such manner as Y to become subject to.Workman's Compensation laws of California." I Signed--------- --`------== - ------------------- ----- �r BYTitle ` ------------------ ------ ---- ------'------=-- ----------------- -------- (if otherthan owner) ; FOR'DEPARTMENT USE ONLY # } DIVISION OF LAND NUMBER...... --- ----- DATE--:------------- ADDITIONAL / '. .. APPLICATION ACCEPTED BY --------- -----------------------------'--------------------------- DATE 18- _311.-- --- - -------- --'--- I ADDITIONAL COMMENTS_______________________ ---- -- -------------------------------- ------ ------------------- --------------------------- - --------------- ------------------------------------------------- ------------------- ------------ ------ ---------------------------------------------- Final Inspection b -- _ -- ---Date- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 23677 REV. 7P