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i FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .......... . ...... . 7 � 7 [Complete in Triplicate) Permit No7f Date Issued-.--_i9.21�;, ••••••••-•----------------------- This Permit Expires 1 Year From Date Issued t 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 R les and Regulations: l JOB ADDRESS/LOCATION -------L . 75.. ......C�Lt.�r.f�L.b--.- �a.�.. _... CENSUS TRACT....................----...----- - Owner's Name.._. ._.. � .1.-C ._._�.(�.Q.E.2Qla....-- ---- ---- .... Phone Address - -- -------------- City---: ---------------------------------- Contractor's ------------------------ ---- --Contractor's Name--------------��'2.,R!S..L\.._/•1-�. S_._.. - ---.-. -_-----.License #-------.------------........Phone......._............... --------- .. .!1 - y-• n_ ��_ _ res serve: Residence ED Apartment House.E] Commercial ] -Trailer Court F _ _ e Installation will s tel ❑ Other__ _ _ _____________________ _--L. - + 5 irumwC1 U" 11viily U11115:- �..•..lvumq or nearooms.....{.' g . �aroa a urinoer..��.v..Lor �Ize.--•-- ........... =-.-•.............. - Water Supply: Public System and name._ . - ........ -------------------------------- -------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt-E] Clay ❑ Peat ❑ Sandy Loam k 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ; PACKAGE TREATMENT [ j SEPTIC TANK [ j Size - __....__. -------- ----------- Capacity,. Liquid Depth. ----------- Capacity.............. .---.Type......---...---- ......Material...............___----No. Compartments --------•------•---- . .,:, Distance to nearest: Well-........ --- - - .........Foundation_..... .. . ...- . ._....Prop. Line.........___---- LEACHING LINE O No. of Lines ---------- .�.,r---�Length of each line......'Q............_Total Length .. ...7--42*.._ . DBox.._�Type Filter Materials 2.. th Filter Material...---- -�d--- --------------------------------------------. - + _ t Distance to nearest: Well...../-.g. .... - Foundation----IV--tz _..Property Line.....d..;.�------..... � SEEPAGE PIT [ j Depth...._'..... _Diameter....................Number- --------_------ ------------ Rock Filled Yes ❑ _No WaterTable Depth--------................................ ......----- •--........Rock Size........ ---------- ---------- Distance to$n-earest: Well--------------------- -_-......--------.--Foundation.. 1.6:.....`. - Prop. Line.....:..------.......... . -. REPAIR/ADDITION! (Prev. Sanitation Permit#----.----_------------- ...........Date................- ....--r---.--------------- Septic Tank (Specify Requirements) -- ----------------------------------- ._........ ----- Disposal Field (Specify Requirements)-- ------------ -- -------------------------------------- --� ------------------------ .......-------•----- -- -- ------ . =-------••-----••-------- - ......_...... ......---..----------------- - ........... ------------------- --------------------- --------- - (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 [ 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 tly performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subi t to man's mpensation laws, of California." y. Signed-- _... . ..Owner i Title...... k+�c,,g /Z------------- - ----------- ..... BY - ----------------------...._. �S -i- (If other than owner) F DE ARTME USE 9NLY APPLICATION ACCEPTED BY /Lt .-- --- - ...-- ..--------•------- DATE .... � q..?�.............. ` DIVISION OF LAND NUMBER....-- -- ---- DATE - ADDITIONAL COMMENTS. ------ // ............. .. ........... ..... . ..... . --------_--_ ----- - ___...... F ------------------------..------------.--------------------------------...................-------........------------.----...------.-------------------.................................. ..._........_..... ......................................... ...... .. .............._... ---..-..... 7—----.........----------------- --------------- - ------------ .-----------------' Final Inspection by:-.... ... ---------- ----------- ------------------------------ --- -..Date.....�^ Q� EH 13 24 N JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 71776 33M