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FOR OFFICE USE: LFOR OFFICE USE: *;P 1 pv) P` APPLICATION FOR SANITATION PERMIT I � ....................... `.> Permit No.'? - 0-4 .6. e " 4 /� {Complete in Triplicate) ------------ �----------------------- [ .;` rDate ......................... 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 incompliance ith County Ordinance No. 549 and existing Rules and Regulations: IJOB ADDRESS/LOCATION.. . --. u�ryr�s- /�-�---------- '.. r lI� = - --------..CENSUS TRACT--- --------- Owner's Name.... ------ �i.S` xc -f�!',LEK --------- --------..Phone _127_1747::...1 Alf l Address-- 1 .( .�.....�.v� =-------------------- City / t� = Contractor's Name--------- - - -------------- --------------------- ............ .................License #---------------------- Phone................................... Installation will serve: 5 Residence Rr"' Apartment House ❑ Commercial ❑ Trailer Court ❑ *! Motel [3- Other:........ . .. ... - "Namber of living units:: ". Number of bedrooms._.. Garbo e Grinder..":...Lot Size""" ...... Water Supply: Public System and name r!LA e. j_f.-:---- . ............ - ..-.......... - Private �1 Character of soil to a depth of 3 feet: Sand � Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ ' Hardpan ❑ ? Adobe 0 Fill Material._ _--- --- if 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 it permitted if public sewer.'is available within 200 feet,) 1 PACKAGE TREATMENT ( ;] SEPTIC TANK [t.}� Size---------w 0-Cp.--- rr. -„�s'--------------------Liquid Depth.---:'� ...-----------"-© Capacity-/�� :rq_..Type P r.r�<ir� ....Mate-real ..:No. Compartments------- ------ -- OQ Distance to nearest: Well-------- .I -.� ...Foundation._-- .... ..... ..Prop. Line-------- ---...-... . ” LEACHING LINE [ ] '-No. ofLines �•--'~:^":'��"~'9`:.:..Length of each line........�'4`. �Total Length .. - ........ --.-- 'D' Box..:..::-; . Type Filter Material/)-& :...._...Depth Filter Material------------.....................-------.-........... ------- Distance, nearest:arest: Well .f __..-.Foundation------ •--_-_---Property Line---------- ....................... r SEEPAGE,PIT ( ] Depth_..... Diameter----------------....Number__f"�--------:,---------------- Rock Filled Yes ❑ No Water.Table Depth- ---•-•------------------- - Y ....... -----...Rock Size.. ---.. .. --- --- Distance to nearest: Well----- ------------------------=------------Foundation. Prop. Line.. t REPAIR/ADDITION.(Prev. Sanitation Permit#................. .......---- ---`- - -----..Date------------- ----------------.----........_) Septic Tank (Specify Requirements)_--- --._... Disposal Field (Specify Requirements)-- ---- ------------ ------- - :._:...-----....-•---'--- --•• ..................... . ---------•-•------ ---."---- --------------------------- ------------ --- -------------------"--------- - --"-"•---------- --------------------------------- ------------•---•---------- -- ------------ ---- -------- ------ 1 (Draw existing and 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 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 tobecomesubj ct to W pensation laws of Califori5ia." Signed_._.._=-� .. �wC] Owner jBy- ----- .............. .......... Title... .... ---- -------- -------------- -------------------- (if --------------.---(!f other than;owner) 1. F DEPA T ENT USE ONLY APPLICATION ACCEPTER BY 7-"� ... __ ___-DATE ........ ... ........... �DIVISION OF LAND NUMBER.... ---..._ . --- --- ---DATE-------- -------------- --- ---------- --- ADDITIONAL COMMENTS.............. ...........- -...------- ---------------- --- ---------- ------------ ----- ..r Date... Final-Inspection by:_._..� .- " t�� ' Fos 21677 aev. 7176 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT6P