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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT A r�lf^ /� %► Permit No...IFWM�_Z5 � -----r' .-- - "-"- (Complete in Triplicate} z i .. �k 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: f JOB ADDRESS/LOCATION- " - ___g_9 -r ---------------------------------------- --"-- .-.CENS TR �---------- ---- �r Y r l F �r ; Owner's Name. ------ Address--- ----------- ------------------------ -- -- Phone-jL2W - Address --- --- --- City_ f=---- ------- ------Zip- -------- ------- f -------------------------------- ----Lic } l Contractor's Name___-_- License �9 �� Ie4 - ---- - --- � - -,--- -- -- --� Phone--- --- -------------- Installation will serve: Residence Apartment House.❑ Commercial ❑ t 'Trailer Court ❑ Number of living units:--/---"- ' Motelt❑ ��-Other-------------------------'------ ------------------ Number ---_..------__-- -' -- . ]. � • Number of.bedrooms--- .--.Gar.ba a Grinder....-._.„__ 61t Size__.___ _._ g g ------------- Water Supply: Public System and name-i----------I-- --------- .- _ __. - Private ` f Character of soil to a depth of 3 feet:�Sand-E- Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe.[] Fill Material_.._______-If yes, type"----- ---------- -------------. (Plot plan, showing size of lot, Iocdtio.n_of system>in relation to wells;, buildings,_etc. must be placed on reverse side.) NEW INSTALLATION: ' -(No septic tank or-seepage pit permitted if ublic sewer is available within 200 feet,] t PACKAGE TREATMENT [ ] SEPTIC TAN© Size_” ` ! V .. a� _x�f�- -- --- ------------Liquid Depth----- ------------- C: Capacity-Cdr-------------Type - $_`-- � _Material-�d�'" ------No; Compartments--------------'_�-------------- Distance to nearest: ---------------:----------_:--Foundation. Q------ -----------Prop. Line__7_.5--.__._______._. LEACHING LINE Na, of Lines- _______________________Length of ach line-7___. _ _=,yQ,"_,Total Length.-___ _ Q__�_---------- D .. - ! .. t D' Box__`r.-Type Filter Materials _ _Depth Filter Material-----.✓�-__._______.__---------------------------�__ ., ,. . . Distance to nearest: Well--. Q40� p y �►�_. p Faunclation.__° __Q�_!__"._:.--Pro ert Line_ _ 1 SEEPAGE PIT De th.,,2-_5___ Diamete'r__03 - ---.Number......vF-_____---_----- ----- Rock Filled : Yes No ❑ . . ... .. . �/ �� .. Water Table'Depth----------- Q: Rock Size:G7K_ ---------------------- --•---- Distance to nearest:'Well_ _ _-�-------------_-:___-_-.Foundation--:o9/e_'___----_---.Prop. Line___OZZ---------------- REPAIR/ADDITION (Prev.-Sanitation Permit#:'__ =` ------------------------ = :Date- _-' = l f 1 Septic Tank (Specify Requirements)----------- = -' --- �. Disposal Field (specify.Requirements)----- -- -_ ----=---------- `- - -------- ---- - ------------------------------------� ----=------- - •- ------------------------ , ------------- ------------------------------------ -- ----------------- - -------------------- •------•------------------------ ------------------------------:-- -- ------ -------------=-------------------------------------------------------------=------------------------ - -------------------- 4 (Draw existing and required addition on reverse side) i I hereby certify that t 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: f "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 becom lefo Wor ans�op. ensahrlaws of California.Califar - Owner Signed - ' ------ BY = ---------_ :Title y G llf other than owne F R DE ARTME VT MSE ONLY '. APPLICATION ACCEPTED:-BY-'- = �y�,r<-=. - '� ------------------- -DATE ------ � � DIVISION OF LAND NUMBER- ---------- -------------------- ---- ---•-------- -- - -DATE----------•---- .:, ADDITIONAL 'COMMENTS------------------------- --- ----- ----------------------- - f... -----=----- -------------- --------------- ------------------- -------- s . . : - ---------------------- =--------- -." � ------ ------;------=------- Date_ ---- - ----- - EN 13 24Final Inspection by _ SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M r.