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FOR OFFICE USE: FOR OFFICE USE: APPLICAT.JN FOR SANITATION PERMIT (Complete in Triplicate) Permit NO...._7.............. Date Issued_____/o_-/$P-_>J_ ...... -- -- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and s t wrein described. This application is made in compliance nwith County Ordinance No. 549 and existing Rules and Regu a i n : JOB ADDRESS/LOCATION.1 '_7F --=Y- f �n.- - - - CENSUS TRACT.-------- n - Owner's N��a//me._-_l`t-_ _.-_ Q_lC'.._C.��' _4�1'!.e f Phone.._,! Address `71 _... i"G(G' -------- - ----- Ci ( f. tY-_/- -�� 11w - Zip--- 5 Contractor's Name--- ---------------- ----------- ------ --- -- ----------.-License #----------- ----------------Phone.------------ - ----------- Installation will serve: Residence'[ Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------- ------ Number of living units: /. Number of bedro�orl7s,.--.3---Garbage Grinder------ -----Lot Size------10 ------------ Water Supply: Public System and name--------�(.1_..�--------------- ------------------------------------------ ---------- ----------------------------------Private Character of soil to a-depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam` Hardpan E] Adobe E] Fill Material_...____if yes,type________________._.__._____- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Noseptic tank or seepage pit permitted if public sewer is vailable within 200 feet,) PACKAGE TREATMENT ] `Y$EPTIC TANK [ ] Size-_---_-` _.__ _____________________Liquid Depth---------------------- Capacity_M&P/--_Type!!`tCompartments_._.-__ o_----- _istance to nearest: WellQrd ' -- - -_________________ _ _ o-__-__ rop. ne__ T -___--- LEACHING LINE [ No. of Lines---___--------------------Length//h�of each line-------- a_____--Total Length __._..l v_-T_7__D----------- Oq 'D' Box_.--_____Type Filter Material_Az�__ ---__-.Depth Filter s� Material___ _ !/!ldm'..______V__Stance to nearest: Well pro -e--r Line_ Z SEEPAGE PIT [ ] Depth__oi_ �� _Diameter_—5.$ __Number------ �__________________ �[ ,Q Rock Filled Yes No ❑ Water Table Depth--------------- - ------------------------------.Rock Size ��T__-/ °�-------------- Distance.-to-dearest: Well----- ._.- _...___._._.__..Foundation...1�d_L.l_'�__.Prop. Line _ - !__-_� -OPAIR/ADDITION (Prev. Sanitation Permit#----------------__.__-_________.._---____._____-Date_._.________-_--__--_--.-_----__-__-____ ) Y, "Septic Tank (Specify Requirements) ----------------------------------------------------- ----------------------- - -3 Disposal Field (Specify Requirements,L------ --------------- ----------------------------------------------------------------------------------------- ------- ---------- ----- ----- -- - ------- ----------------------------------------------------------•-------- ------------------------------------------------------------------------ --- - - - ------ --- -------- - ------------------------------------------------------------------------------------------------------------------------------------------ ---------- (Draw -------- (Draw existing and required addition on reverse side) I hereby certify thatil hav"repared this application and that the work will be done in accordance with San Joaquin County Ordinances, State �c ws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature.certifies thee.following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Work n Com e� laws of California." Signed--- �0 ------------Owner --------------------------------- BY-------------- ----------------------------------- ------ -------------------- ----------------- -Title----------------------------------- ---------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ------------- t ------- - -- ----------------------------------------------------DATE DIVISION OF LAND NUMBER.----' =--------------------------------- - DATE ADDITIONALCOMMENTS- ---------- ------------•---------------------------•-------------------------------------------------------- ----------------- - -- ---------------------------- 1 ?' � - J!TS -------4-lG----------� ' =---------- -- - ---------------------------- ------------------------------------------------------------------- ------------------------------------------------------- ------ ------------------------------------------------------- ------- -------------------------------------- -----------------------------.. ---------------------------------------------- -'--- ----- ---------------------- -------- ------------------------------------ ------------- Final Inspection by: ------Date //�l�r EH 13 24 SAN,JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7176 3M