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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.---7-7_ -7 1 { ---------------- Date Issued.__-//--,?/--7 --------------------------------......................................... --- This Permit Expires 1 Year From Date Issued 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. r This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION..........l.y-)-.---- ------O ------- _ : l ; S TRACT Owner's Name M ------------------------------------------` iPhone----- ------------------------- --- -- r --' .... --- -------- _ - -------------- Ci Address -,.� - z-. lc 1 : ty Zip[ F Contractor's Name------------ .. ) - ---:-----•- ��eent �- ---' ---_'----.__License _.7/�.3_j_'__.Phone--T'-- - - ,i;...Installation will serve: Residence House ❑ Commercial ❑ `Trailer Court ❑ : t ' Motel ❑... " Other------=- ._-.Numberof,be'drooms ---Garbage e Grind44--Lot,Size__ + y -. ---- Water SuPPIY Public System and-name Nutuber of living.units:______._ -- ----------------------- rivate Character of soil to a depth dean❑ , Adobe �; F'illlMaterial_.�✓v lay �ySandy Loam ❑ Clay Loam ❑ kf es, pe-- --•_--{`" ---- (Plot plan, showing size of lot, location of system in relation to-wells, buildings, etc.fmusi be placed on reverse side.) NEW INSTALLATION- .(No'septic-tank or seepage it permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT- # [ ] . SEPTIC TANK- .[ .-!' iie_=�--'�-�__�_--��:-�� --=-------------------Liquid Depth-----��2_--'---- Capacity-)z -----,,,Typ' -- =7� ' --=_=Materia ) -------iCompartments.' �------=------ ------ S s Dstance to �_.____.__.. Foundationw-- --J_._._..Prop: Line_:. LEACHING LINE,'—[L]/No.hof Lines _` _ .,.Length f each line.:_ �!q.Total Length.:_ ------------------------- 'D' �_______ _______ __ D' Box. . PS--Type Fi]ter Material:_ CC�_:Depth Filter Material__...I. . _ _......`----------------------------------'.._.Q Distance to nearest. Well_`•__ _ _ Foundation___:_ f Property Line----- t SEEPAGE PIT [ ] Depth----------------Diameter----------------------Numiier----_ -------- ; Rock Filled Yes ❑ No ❑ Water Table Depth-----------------'--------------------------------- '-,---.Rock Size- ------------- '' t Distance to nearest: Well -- ': ...Foundation'] ---. Prop. Line----------------------- REPAIR/ADDITION-(Prev. .----- -- -------REPAIR%ADDITION (Prev. Sanitation-Permit .------- --- Date------?---------------------------------------- Septic ------------------------------Septic Tank (Specify Requirements)-- " ----:--------- Disposal Field(Specify Requirements):, - 14 ----------------------- - (Draw existing and require dition.on reverse side) f hereby certify Awl 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-Son.Joaquin-Local-Health-District.-Homeowner or licensed agents signature certifies the following r, "I certify that in the performs cerof`the work for which this permifis issued, .I shall not employ any person in such man er as to become. subject .to.Workman's Compensation laws of California." Signed- ---- ------ ------'---- - -----------------------------owner B ----- ; Y ---- ,--- --------------f it e------------------ - - i ":F EPARTMENT USE'ONLY. ! APPLICATION ACCEPTED - - . t--=----------- -!s �:_, '- - ---- ---- -----DATE._/f .2 DIVISION OF LAND NUMBER------- ---------------------------`-------------------=--------- I--'------------- - DATE-=----------- I ' ------------- ADDITIQNALCOMMENTS. - = =------------------------ ---------------------------------------------------------------=-----I------ -------------- -- i r _ ! ------------------=--------------=---------- ;- -------- ----- --------------- _---- ------------------- -----------------I------------------------------- ----- ----------------------_-------------------------------------- ------- ----- -- - - ------------------------ ------------------------ ---- -- ----- Fina€ Ins ection b Date ._. - - ------- - - - --- - - --------------------- EFi 6 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7(76 3M