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FOR OFFICE USE: + i APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: { p ete in *l Cam I Trip icate} Permit No7 _---- - w This Permit Expires 1 YearFrom Date issued -------------- - �•�! ------------------- This--- - wDate Issued/6---- --- - -- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein de This.application is made in compliance with County Or ' nce No. 549 and existing Rules and Regulations: _ �^7 scribed. k JOB ADDRESS/LOCATIO y i ` e7i --------- --- i- -.CENSUS TRACT--- Owner's Name- -------- �. a - - - • --------------- ---------- -- Address.- - C� - o _ /- ----- ------------Ci ' Contractor's Name_._ , ----Zi / --------- . ------ ------- ----_------ ----- :License #_C .,1fe� � Installation will serve: �- "' I �` � - --� n -� ._ Pho e_ - _ a�C/la Residence i� Apartment House.❑ Commercial 0 r,Trailer Court ❑ . / .. Motel ❑ Other � --- -- _Number of living units:___--- _Number of bedr ams.- _ - t -_ Garba Grind Lot Size_"- 5 Water Supply, Public System and name____.___- - _ . Character of soil to a de th of 3 feet: Sand -- -. Private Character ❑ # ❑ Silt❑.�C ay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ € Hardpan 0 - Adobe: �- rill Material°'. -�If yes,•type==-- -•-" ------ -'---- --- - (Plot plan, showing 'size of lot, location of system in relation tofwells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: `(No septic tpnk"ar seepage pit permitted if public sewer is available within 200 f PACKAGE TREATMENT [ ] ; SEPTIC TANKSize ` eet,] --------------------- ["] -- ------- -- -----Liquid Depth Capacity = `= -. TYPe = Material ---:-- ------- ---No. Compartments x Distance to nearest: Well_---------__- LE�CHING LINE: t ------------- --Foundation,--- ------ --------------Prop. Line-------------------- _] No. of Lines.:_'_,_____._-__- _.-___.-_..Length of each line.- D' Box :•. --------------- ...Total Length - -* --------- I Type --- -------Depth Filter Material.--- „�"" — - .....-. ------------------------------------------------ -Di _ � stance•to nearest: Well-_.__.___-- Yp iter Material -"--- ---Foundation Foundp#ion"-____.____-- Property + . :. �. .. SEEPAGE PIT me-- ---- - - [ l Depth ---- D.iameter-•------=-----------Number--- 1W - ------- R ' - - . . �. -- . Rock Filled. Yes 0 --- N %o ater Table:Depth---- --------- - t s- - - -----------Rock Size=--- -------- A _ o [fib t Distarice`'to nearest: Well. '-_-•___-___ - _ . -r� f` Foundation- r ` - Prop, Line-------- =�------ � REPAIR/ADDITION ]Prev Sanitation Permit# - _- - , . Date Septic Tank (Specify.R�quirements � , Disposal Field (Specify Requirements) � � ___3 -- • -------- -`'� -- - - ----- -s - ;It -- � '- (Draw existing and required addition-on-'rev erse side) i _- y 1 hereby certify that I have prepared this application and that-the w+rrk'-will"be done in accordance with Sant Joaquin County Ordinances,- State. Laws, and Rules and Re's ulations_.of,the.,.Sq Joaquin.;LocaL..Health:district• Home owner or licensed agents signature certifies the following: "1 certify that" the performance of the work for which this permit is issued I shall not employ an + to becomefE ett o Work s Co ensation laws of California." �- p Y Y person in such manner as Signed..... r t t - BY`-----•-- ----- f} 'Owner ..� -- Title." - ---- �-•-- ------ ��---,••.mow If of r [ her than er FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _-- __. _4 OF LAND NUMBER._. ------------------------------------------- DIVISIONd DAZE.'_,�Q ADDITIONAL COMMENTS_.. ,- f --------- = = DATE -tela -------- ------ ---- - --------------- � ' � - - --------- -------------------------------------- ---------- ---------------- --- ------=---•---- ------ EH ---- .- - Final�lnspectron by: LL1nN_ - ------ ----- - - - - 7- SAN - EH 13 24 - -- ---SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.