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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ I�------ (Complete in Triplicate) Permit No--- 11-:......_ ------------------------------------- --------------------------------------------------h___-_ This Permit Expires 1 Year From Dane Issued Date 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 coni plionce with County Ordinance No. 549 and existing Rules and Regulati-ris: JOB ADDRESS/LOCATIONSCQpS_JVC - --- -- j__r1.4Q ---I&M .--,l�l_LPaA)-----------------------,CENSUS TRACT.---------- -- r � _ .. Owner's '-------- ----------------- -----------------Phone_ IT,.s ------------------------------- ---------------------------Zip-15,7364_---- Contractor's ip-15,736 .------ Contractor's Name`. } - - _--- 411knee -------------------------------License #.�__7 T71 --._Phone__ Installation will serve: Residence Apartment House ® Commercial ❑ Trailer Court ❑ . Motel ❑ Other_------------------_----.._..__.....:--_...... - Number of living units:__________.___:Number of bedrooms__3_ Garbage Grinder'" _.�- Lot Size____ .._ - Water Supply: Public System and name------- --- ------ ----- -------•------------------------- --------------- --,.-_Private Character of soil to a depth of 3,,feet. Sand E) .-Silt , Clay Peat Sandy Loam Clay Loam ❑ Hard an Adobe Fill Material-_ ___;_...If es a _-___..___ pad ❑ ,❑ yes,type..................... [Plot plan, showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.) 0 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) y .�..� .-, ..,. �...... r_.,.a Liquid Depth._ - - PACKAGE TREATMENT [ ] SE PTIC TANK [ } Size-__-__---- __----------•____-_________.____ .IM t - Capacity---------------------Type--------- --------------Material------- ------ ---'No. Compartments--------------- ._....OQ Distance to nearest: Well---------------------- --------------- Foundation---------- . -----..----.Prop. Line_•--.-------.---__-------- LEACHING LINE [ ] No, of Lines_.-----. - ------- - --------L .-,,-,Length of. each�line- -_-:`�A_-------_ _.Total L_ength_ ........#, -------------------- ��._.t- _..-------.------.--. D' Filter y_ �k_Depth Filter Material__- IM. " � I-.,A � e Distance to nearest. Well _�_____T_ __ `>" Foundation___�A..................Property Line----�,.5------------ SEEPAGE PIT. [`] Depth]iI.I___ -------Di'ameter_ ." _ .;' Number___._____I___________________ __ Rock Filled Yes No 1 x Rock Size..--- A II WaterTable Depth------------=--------------------------------.....-..... �I-----------..........._.-------------- Distance to nearest: Well___'10q___:____"-____-_____---_Foundation---ASV.....t:___.__-Prop. Line----�5v................... REPAIR/ADDITION {Prey- Sanitation Permit#___________a_______ _ --------- Septic Tank (Specify Requirements)____.----------------------------------- ' Disposal Field (Specify Require)Tents)-------_--------------- _ __°'"._ - ---------------------------- ----------- ---- o. 3 11 _________________________________________________ - _ ... -0------------------------- I� (Draw existing and required addition.on reverse side) {` " I hereby certify that I have prepared this application and that the worm will be done in accordance with San Joaquin County Ordinances, State Laws, and,I�Rules and Regulations of the San Joaquin Local Health`District, Home owner or licensed agents signature certifies the following: "I cern that in the II certify performance of the wank for which this permit is issued, I shall not employ any person in such manner as to becom ub' t to Work n s Compensation laws of California." `7�1�'-- Signed-- - --� - - ------ ---- -------------------------------------------_Owner BY----------------- II----------------------------------------------------------Title------ •- ----- (lf other than owner) i s FOR DEPARTMENT USVONLY. APPLICATION ACCEPTEDBY - ---------------- DATE DIVISION OF LAND NUMBER.---IM------------------------------ ------------------ - ----------------DATE.--------------- ADDITIONAL COMMENTS--------!M>----------- -------------------------- - - ----.. --------------------------------- ------------------------ --- ------------------------------------------------------------------------------- I1 . Ili ------------------------------------------ - --------------------------------------------------------- ----- ------- Final-Inspection b -- iE_ -----------------------------------------------------------Date. -L7 ------------ 9H 13 24 SAN AQUIN LOCAL HEALTH DISTRICT F&S 21677 3M