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FOR OFFICE USE: FOR OFFICE USE: .. ""' APPLICATION FOR SANITATION PERMIT `72` 4 37 (Complete in Triplicate) Permit No________________ ____ Date Issued- ------------------------------------- - ---- ssued_________________-___-.--____-_-_-__-__.____.____---__ __ 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: y - z JOB ADDRESS/LOCATION- ., ___G �n x,71 - ``� �`JiA f!-w ' ��.CENSUS TRACT Owner's Name -le - nG Address-------------- ' 1"F.e"t- y ,�------------- :- -City----� ' �-j ZiP 1 Contractor's Name-.- �J/Y7t�7�� `' �4.�_�. _ _lLicense---------- --------------- Phone Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------ --------- --------------------- C Number of living units;--I/----------Number of bedrooms ____..Garbage Grinder....--------Lot Size------- ___ ________________ .......... Water Supply: Public System and name--------- ---------------------------------- --•--- --- ------------------------------------------------------------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________________---_____---_-__ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) + NEW INSTALLATION: i(No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-__ ___ _ ?K-i ------ ---------------Liquid Depth /ter Capacity. "C------:TYPe , --=J-X-Mataria//l ? ----------------------No. Compartments---------------------------------- Distance to nearest: Well._._ct�7- ------- ..---------I-____Foundation) ___i.____.___-.Prop. Line___ Ca.�_________� LEACHING LINE [ ] No. of Lines---- -_______ ____.Length of each,line.. . Total Length A45 -------------------------r D' Box- Type Filter Filter Material----le*v -------------------_----_-------------------- __ Distance to nearest: Well___ c' r---------A/.Foundation__"P--6? ----Property Line._ SEEPAGE PIT [ ] Depth------ ---------Diameter.......- ---------Number-------------------.------------ Rock Filled Yes ❑ No (] Water Table Depth-----------------E---------------------------------------Rock Size------------------------------------------------ � r „ f Distance to nearer#: Well_____________ _---------------------------Foundation--------------------------Prop. Line.______________._________ REPAIR/ADDITION (Prev. Sanitation Permit,#---------------_-------_-----------------------------Date---------------------------------------------- Septic -_-__-_--___-_-________-__-_______--_________Se tic Tank (Specifyy Requirements) ----- ----------------------- = _ " i Disposal Field (Specify Requirements)___`_______---__----- __________________________ _ -----------------------------------------------------------I------ --------------------- -i 3 ! ------------`----- '___-__- <--------------------------------------------------------------------- -----'----------.----_----- -,'---------------------_--.----------------------------------- ' (Draw existing and required cgddition on reverse side) i hereby certify that I have prepared thisapplicationand 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 i 1 k "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 subject to Workman's Compensation laws of California.'.' Signed-- _ lu ---- ----- ------------------ --- ----- - ------------Owner -- - - + BY-------- ------- - ;' r ----------------I+-----------------------Title.--- ---- . -- (If her than owner) + u FOR�DIEPARTMEN�USE ONLY APPLICATION ACCE=PTED' BY_-- -------------------------------DATE DIVISION OF LAND NUMBER- -------------- --- ------------------------------- --------- --------------- ------------ -----------DATE--------------- ---------- -- ADDITIONAL COMMENTS------------------------------------------------------------------------- --------- - ----------------------------------------- ---------------------- -------- e k i ------ M t1----------------------------------------- 3 r Final Inspection by K`n�� j -�- �� ------------------------------------------------Date e .�� [ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT �Eas 21677 REV• i-;" 3M