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i ,Q FOR OFFICE USE: � ' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit --------------------------------------------------------- Date Issued_5_-_--'_'_-7_f 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---------1001-1-----5--•------1./.___�-r{ Q - ---------- ----------------- ---CENSUS TRACT--------------------------------- Owner's Name--------J- - with ------ ----- ---- ------------------------------------.Phone--- 7 Address---------- ------ 1----------- - -City--- M'01 C_Z--------------Zip---------------------------- Contractor's Name---------------------------------------------------------------- --------------------------License #----------------------------Phone---------------------------------- Installation will serve: Residence- Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------------------------------- /J Number of living units:-----l_--------Number of bedrooms__ .___Garbage Grinder------------Lot Size_____ .__.._-____________ WaterSupply: Public System andname------------- ---------------------------------------------------- --_---------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam.' Clay Loam,- Hardpan ❑ Adobe ❑ Fill Material_---------If yes, type_______________________--____ r- (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 TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth.______________________-__ Capacity---------------------Type----------------------Material----------------------.._No. Compartments--------------------- -------------- Distance to nearest: Well ___--.-..___---------_-------------------Foundation--------------------------Prop. Line_______________._.___----- LEACHING LINE [ ] No. of Lines-----------------------------Length of each line.------------_------------------Total Length ___________-:__--__--_______-_____-__ 'D' Box------------Type Filter Material--------------------Depth Filter Material--------------------------------------------------------------. Distance to nearest: Well-_______-- _-___________Foundation________-.,;_______ Property Line---------------------------------- SEEPAGE PIT [ ] Depth------------___Diameter___ -.;___,_Number------------------------_ ____--__ Rock Filled Yes [:] No ❑ Water Table.-Depth- - ---- ----------- ----- -- ------- --- --Rock Size----- - ------ --------- --------------- Distance to nearest: Well---------------------------------- FoundatiorL_ __`__` _`,---------Prop. Line---------------------------- REPAIR/ADDITION _ . _______REPAIR/ADDITION (Prev.,Sanitation Permit# _-__L1� _ --_.Date----- ---- --------------- ) Septic Tank (Specify Requirements)---__ _`__ � ___ .--------- _;WDisposal Field (Specify Requirements)_ _. _pl �'L' _v1�`�:�'"5-_ .-_-�- �� / �-�i!i__(l�t.� __-• ------------------------------------ - ------------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and That the wek 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 to become sub j an's Co ensation laws of California." Signed-------- - Owner By----------------- - Title------- ------------------- ------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------------------------- ----------------------------------------------------------DATE.-------- ------------------------------------ DIVISION OF LAND NUMBER. - - - DATE--------=------- --------- ------ ADDITI AL COMMENTS_. ?$______ ._ l --- f---- j` ------------- } --- 'asl---------------------- c-- ----_1l_'--'vl ------------ �h_ -lis--� - -- - - 1 ChS lt�i -o4f 0h 2� �8: Til_.- _ L cl ,'' A -' �t�.�-►-� ' Final Inspection by - -- - -------------- G � --------------------------Date Ci- - le EH 13 24 �j F& _21677 REV.7/ 6 J17el? �a �� SAN JOA UII� LOCAL ATH D19TR (� ^