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q'- FOR OFFICE USE: y FOR OFFICE USE: u APPLICATION FOR SANITATION PERMIT --------------- ----------- Permit No.-- -= (Complete in Triplicate) _ �� -------------------------- - - Date Issue __ ____________ ______________________________________________ This Permit Expires 1 Year From Date Issued 1 Application is hereby made to the San Joaquin Local Health District for a permit to trevct;and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and R g Ictt bm: y . ` JOB ADDRESS/LOCATION. Z Z- 1.n�_ CENSUS TRACT------------------------ i Owner's Name.---1-------� ------------. -------------------- -----------Phone.- V SIM i OS Address �s city Zi a Contractor Is blame i .;- i Ji i-�-- _-- .-- .__ '�� --------------•--`License #� ."�q 3 - Phone- ------------- 6a Installation will,wve- Residences: Apa e t`H-ous-e-ffl -Commercial ❑ Trailer Court [I ' Ote1`❑*�"Other--:---- ---------------.� Number,of living units:_"__-y _Number;of.bedrooms_:__ Garbdge Grinder---- _____ Lot.Size______,. �. _. ._ ___________ ____ Water Supply Public System and name t t: t s ._. ----------------------------------w ------- Private.O i Character of sail-to.a,epth of 3;feet: Sand [-[ .Silt Clay�[-�. Peat❑ SPndy Loam E] Clay Loam ❑ 4 f u!, Hardpan ❑ Adobe77``m s. Fill, Mater ial_..----------If yes,tYPle--------------------------- ---'. (Plot plan, shoiwing size of lot"l�ocation of system in relation to wells, buildings, ktc.;must be reverse placed on side") NEW INSTALLATION. (No`eptic tank or seepage-pit -permitted if public sewer is available within 200 feet,) t PACKAGE TREATMENT [ ] SEPTIC TANK ['] ' Size d_____------_------__------------------_-----=______I____Liquid Depth'---------------------------- { fCa,pacity-=--------------- ---TYPe-----------------.:__�_Material--:° --- --------------No. Compartments ------------ Di'stan`ce to nearest: Well. ." :.��_._ Foundation_.___" ----------Prop, Line-=___.____. r- - LEACHING LINE [ } 'Noof Lines__._____"_ '--___.Length,of eajli Fina-- ________ Total Lea�gth� "!_.___. _ -.-- l I 'D' Box------------Type Filter Material -�`---------Depth Filter Material----- ---------------- ] -------------------. j Distance;to nearest: Well_ � __ Foun'dotion_ -----PFoperty Line_.._---__ ---_ SEEPAGE PIT E [ ] Depth = ._------Diameter---------------------Number-------------------------------- Rock Filled Yes ❑ No Water Table De th'.-""'----- ----- ' ' ------------ --`----.Rock Size---------- �",'.-- ---=----_=- s, to n'eare'st': W611---4 *;�"- F_____'. .__..__. 'Foundation ___ t ------ Prop. Line--------------------------- Distance REPAIR/ADDITION(Prev. Sanitation Permit#t --------------z. ----------_.------------______Date ---------------------------------------- J, __ ____ ______.._.-_ •---f Septic Tank [Specify Requirements) ---------- _„_-'-F---= -�--- =-`- ---=-- -- --- =- --------------------- ----- ---- ------------------------- -------------- ----------------- - 1 Disposal Field (Specify Requirements):------__- -�- ---__.-�"c�r[ �- -- ---- [r G ----- ----------------------------------- -- y rr I i- ---------- ---------------- -------- -------- . r ----------------------------- -•--------- - ---, ------_------------------------------------- - ---------------------------- (Dra 1 existing and required addition on reverse side]" ; I hereb certif that I have re ared this a lication and that the work will besdone-in accordance with San Joaquin County Y Y P P PIP Ordinances, State Laws, and Rules and Itegula:tions of the San Joaquin Local Health District, Home owner or I ensed agents signature certifies the following: f N 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 Workman's_Compensation; laws of. California." Signed------------------- -_---------------- --Owner r B '. ------------- ----- ------------------- Y e :" G� �l J f JF i .T itle � - "' f other than'owner) [ * ' FOR DEPARTMENT USE ONLY r -' APPLICATION ACCEPTED`BY -N - ��-� -----------------DATE. DIVISION OF LAND NUMBER ----------------------------------- -- - ---------- .. DATE :: ADDITIONAL COMMENTS-- -------------------P---------- ----33'- --Y,Z--I--/---------------_------- ------------------------------------------------------ --------------•----------- = ---- ------------------------.--------.------I--------------- -- ---=----------- '------------------------------------------------------------------- -------------------------------------------------------- --- ---------- - , - Final Inspection by=--- �i-" - --a_ Date.. ��/ `l 8------- F FK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos sibs Rev. 7, inn