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FOR OFFICE USE: FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT p � �.� - -------------------------- -------------- - ---------- (Complete in Triplicate) Permit No.7.�J :-n-----... � Date Issued_,7_) 0f Z __)pZ ......• p- -- 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.. _- ._....: .Q. �lf�_.!✓p-- --i��..�.....----.............. -------..CENSUS TRACT................... .......... Owner's Name._.. ... ,ff��r y , 1 ./..T+!=/iL ...... ........................... .. ... .............Phone__ _6/-0e��!f... Address --------- .....-- ct- .. ��j City Zip � �'��:� Contractor's Name-----..h. ..,�.--- --- .: ..... ................license #_c;2.5` ,.�!X ---- .Phone..G:Y _ ...... Installation will serve: Residence ff� Apartment House ❑ Commercial ❑ Trailer Court ❑ II Motel ❑ Other------------------ --------------------------- Number of living units:..-.-1----.---Number of bedrooms....'rZ-..Garbage Grinder------------Lot Size......77/_-%7.. ..................... t Water Supply: Public System and',name.. ................. Private Character of soil to a depth of 3 fEe\',.Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ i Hardpan ❑ Adobe' Fill Material . -... ....If yes, type........................... .... (Plot plan, showing size of lot, location of system in relation to w_ e_Ils.,:6uildings, etc. must be placed on reverse side.) PACKAGE TREATMENT ( SEPTIC TANK- p-' p Size p. sewer is available withiL1200df�e th • u ` - - ,} s NEW INSTALLATION: No septic tank o�seepage iti }erm+ittndi�, ublic �'^=------------------- - -- --- q p -----.-.--.--- - ,. . -� Capacity_1QQ.. ype:P 4ti_- -Zt- Material.-.-C�x?r '::No,_Compartments------�-------------- -V-- Distance to nearest: Well._... 1.:.........................Foundation...��. . _.... ......Prop. Line. --- .Q- ---- LEACHING .LEACHING LINE No. of Lines _. .... .............Lerigth of each line------- Total Length ... .. ............ 'D' Box----..Type Filter Materia�� ,P epth Filter Material.....1g..._----- _------------------ ----------.. ... Distance to nearest: Well...__ .. -------- Foundation-_._-��-..T _._.Property t.............^+ + p �� - , Rock Filled Yes, No ' SEEPAGE PIT Depth ..-----.Number....-:-.-��-_-.__--.-- _:� Water Table Depth------------------------------- .......----.Rock Size.... ......hl d / -- Distance to nearest: Well------ --------- ---;.......-..----....FoundationProp. Line.lS4f.....------ 4 I REPAIR/ADDITION (Prev. Sanitation Permit#-......__ '..... . . ..__.:.. --'- .bate._..----=- ---------- - :.... -) ' Septic Tank (Specify Requirements)-f "''. --- i--- _.`_ . ...-%"` ........ ____ .................. Disposal Field (Specify Requirements).... ............ c... _' . .. -------------- -------------- - - - - i • IDraw existing and required addition on reverse side) I hereby certify that I have prepared this application and that`ihe work will be done in accordance with San Joaquin County i 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 to become s bjec! o War an s Com ensatibn I Ws of California." Signed �4 Y� .-(d -.... ��'-_----- -. .-Owner i BY ---------- ------- --------------------------- ------------- Title.... - ... .. If other than owner) I FORD ARTM USE ONLYI Z } APPLICATION ACCEPTED BY- ------------------- ---------DATE ....--7- 1. 2g-- DIVISION OF LAND NUMBER.-------- ......... DATE. -.... ....... .......... ADDITIONAL COMMENTS.............. ....... .. --------- ........ ...................... 4 -------'^`--------`---------------------- ---- -' - _ ----------- - -.....---- '-- Final Inspection by:..... ----------------------------------------- Date. .. _.. EH 13 24 bAN JOAQUIN LOCAL HEALTH DISTRICT fss 21677 REV. 7176 3M