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FOR OFFICE USE: Nei FOR OFFICE USE: ----- ---- -- --�-�---�- (Complete in Triplicate) ��_ - � APPLICATION FOR SANITATION PERM �7 / =- Permit No._C..7'_-z - �- --------------------------------------------------------- y Date Issued.S-r..--..- _ / ......._-----------------------_...--__....-..___-- This Permit Expires 1 Year From Date issued 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 Rules and Regulations: 'f - --- --- _'.n �� JOB ADDRESS/LOCATION- --------- ..... - .CENSUS TRACT.-----------_---/---- ------ Owner's ,---Owner s Narne--- - ------ -- // ----- ------ -- ----- ---------Phone_-S/'l7 n,7_ �. Address - �D.S�� C9�YL011y ty. .� -Zi - Ci �yn.y p -- Contractor's Name �..�.1 ASE✓S.fF f t M ex.s- __.--License #A��!43_ _Phone__ Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer- - -------------------------- Co�ct E C 0 P Y Motel ❑ Other------ ------- --` r Number of living units:---- -----Number of bedrooms JGarbage_flnfler__.___-Lot Size Areie flg'----.-----------------.------ .__.--. Water Supply:fA"c Systern and name------ ----------------- ---------------------------------------- ----------------------- ............---------=----------------Private r$� Character of soil to a depth of 3 feet: Sand[] -&If❑' Clay ❑ Peat❑ Sandy Loam M_ CI_ay Loam ❑ Hardpan Adobe�J Fill Material______-If yes, type!------------------------------- ' \ i (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 [ 1 SEPTIC TANK [ 1 Size--------------- __�- -------------Liquid Depth.-------------- ._....,..t Capacity`-------- ----- --.Type- -- --------- ----Material_ _ _ _ - ------ _ __,._No. Compartments_. _-----------------------------_ __ __._) - Lv Distancelto nearest: Well- .. .... -.--. -----------------------Foundation .--_ --- ------Prop. Line ..-------- - .. LEACHING LINE -(A--No. of Lines_ ------------- Length 'Of each line'._ _ Total Length - _--------------------------------- v - -_- _.- v Box---------_ Type Filter Material-- --------------- Depth F}tor Material------------------- Distance to --._.---Distanceto nearest: Well..--------------------- -Foundation.. \ ---------------.Property Line _ _ . ___------- SEEPAGE PIT [ ] Depth...._ ......__Diymoter_:-.----------------Number..... ----------------X;------- Rock Filled Yes ❑ No 0` Water Table Depth. .. -------------- - ----------- -------------Rock Size------------------------------ --- Distance to nearest: Well. ----------- -----------------------------Foundation--______-------------Prop. Line. REPAIR/ADDITION (Prev. Sanitation Peyrr�mmit��#--------------------------------------------- -__Date.-._ --------------_----_______.---) Septic Tank (Specify RequiremenTs).._.�QC s_, _.- ----- - - --- --- --- Disposal Field (Specify Requirements) Q_.- _ _. .. --- (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 Therformonce of the work for which This permit is issued, I.shall not employ any person in such manner as to become subject orkma 's Com ensafion aws of California." m /� r Signed----J0-01-Qa- kf ------..._.__.OwnerBY---------------- _ ---- -- ------ ---- �--------Title__—I --.._.... - --(If other than w EPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - - - - ----------------------- - - ---DATE. - DIVISION OF LAND NUMBER. - - -- ------------- ------------------------------------DATE.--- ----------- ------------ - ---- ADDITIONALCOMMENTS---- --- - ----- --------------------------------------------------------- ------------- --- -- - ---------- - ,1------------- -- y- ------}� c3------- aa-�-----�a�rd`r ��`� [ �rci.i r /�ns - ---- --------------- ------ --------- - b r - /�7�r f '-- /�s1 Jjar��s yc- -` - --- ... - --------------------------------------- ---- --- -------- ----------'------- -----/----------------------------------------'---------------------------------------- Final Inspection b ----- - - - - ---------------Date. �_ = P� Y` - - Ex -- - et 13 24 SAh OAQUIN LOCAL HEALTH DISTRICT F 47677 REV. 1/76 3M 0