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ti " FOR QFFiCE USE: " FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT } ---- ------------------- -------------------------------- P plicate) (Complete in Tri Permit ------------ ------------------------------------_;---.-_ This Permit Expires 1 Year From Date Issued Date Issued_F_./4_r2%,P-1 Application is hereby made to the Son_JoaquinyLocaf`Health District,`for a per,mit,to co1xstruet,,and install the work herein described. This ,application is made in compliance with t - County Ordinancei No:549 and existing Rules and Regulations: JOB ADDRESS/LOCATION----.-- -- .-.----, --- T i -------------- ---------CE i NUS TRAC Owner's Name. = ---- - ------------ -------- ---------Phone . �..,. Tom' • t �-..:_ ------�- - ------ . �------ Address-------- Jo = �0 1 - ` -------------- city -- -----Zip----------=------------------- Installation wilts ve: .' Residence� i License #--- - Phone--_- - Contrpctor's Name_..__. / ` J� [ s Apartment House.❑ Commercial ❑ Trailer Court ❑ ! +' { teI ❑• Other----- °--------------- Number --- -----=- Number of living units__ _______ /___Number of bedrooms. Garbage © -� i} .Q Water Supply: Public System and-name-------- - ------'=�' _ -- ---------------------------------------Private ❑ Character of soil to.a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat E]/Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe ❑ Fill Material _.._.�If yes, type___ ______________________: {Plot plan, showing size of lot, location of.system in relation,ta_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,] A PACKAGE TREATMENT [ ] SEPTIC TANK '[.] Size---------------- ---------------------------:-----Liquid Depth . ------------------------ Capacity__=' TYPe = Material- =-------- .--,"No. t No} Compartments = = t j Distance to nearest..Well- ----------- -----;--•.--,Foundation_-_----- -----''_-Prop. Line--------------------- wl LEACHING LINE ( ] No.,of Lines----------------°-------_-_.--Length of each line ------------ Total Length _______ ___.__.__. ------- - 5 ' YP Material----- —___-^'-'Depth Filter IVl eriaf r ` . Distance to nearest: Well-_ D' Box__.___._�T �e"Filter F --- ------- Foundation Property Line ----- --- SEEPAGE PIT [ ] Depth_ __ .....Diameter-?------------------Number------------- ----------- -------- --:- ----- Rock Filled Yes ❑ No ❑ WaterP1.th--- (... y ('Distance to nearest: Vti/e(L---- ----�---'---- -=---�--------- --- ---- Rock Size_-- ---=-- -------------------------------- ---- -------_------- ---- � r F / Foundatio_ ---------------- Prop, Line F = ' E --------- �-- i REPAIR/ADDITION (Prev-.,Sanitation Permit#_J :__--- ------____-- ��_-- ---_ Gate._-' - --------------=-----] Septic Tank (SpecifyRequ€rements)._ ---------------------------- ---------'-'- Dispos Ifiefd pe ify Req 'rements} -- -- -- - ------- 77t_: l - - ------- ---- „ --�/// ------------------=--------- ---------- --- ---- ------- -- ---- _ =----------=----------- ----- ------------------=---------- ----------- , {Draw existing and required addition on reverse side) { I hereby certify that "� ave prepared this application drid that the' work-Wilt'Ve d`o`ne-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 followings "I certify that in the performance of 1the work for which this permit is issued, I shall not employ any person in such mannertas to Compensation laws of California." ia." 4 i Sig 3 Si edome subject=to--Workman s Comp. --- ------------ --- -Owner _ 44 BY- --- ----- ----- - Title ' - = f of e7 t an 'owner} FOR' EPARTMENT USE ONLY APPLICATION ACCEPTED BY ='' ------ --- -----e:_ - ------------------------ --------------DATE.------- -----'-=------ ---- --, DIVISION OF LAND NUMBER ------------------------------------------ ---------------DATE------- --------- ------ ---- ----- ADDITIONALCOMMENTS - x� - --- ----------------`--_-.-- -=---------------------------------------------------------------- --frr� --------- ------------- --- r------------------------------------------------------- ---- ------------------------ --------------------------_----- ------------ � __ �!cyf€ ------------------------------------------------ �f- -------------------------------- ---------------=----------� -------------------- Final Inspection b - 7 g P Y -= .' - ---------------------------------------------Date --- ------- ----- ---- EH 13 24 SAN JOAQUIN°LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3W i