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s 1 :-FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR.SANITATICIN-PERMIT 7 7w s- � �.� ��.---- - Permit No---- -------------- -- (Complete in Triplicate) ------------------ ------------------------ �� 7 - ---- Date Issued ----------- °,_¢,------------ ___,______ This Permit Expires-1_Year From:Date Issued,,,,,, Application is hereby made to the San Joaquin Local Health District for a permit to constrA and install the work herein described. This application is'm'ade in com fiance with County Ordc� and existin Rules and Regulation _ x • (..�C..�.. NSUS -- ----- JOB O _._ - I' 1 Owner's Name --:_ '�'� ' - - Phone--- Address_.- ' :_ � ----- - - --- - � --- --- City-- - ;. _ Zi .. Contractor's Name . License #r' .r_94X � Phone--- �=�� 0 17 i i ..„ Installation will serve: � Y Residence Apartment House.❑ Commercial ❑ Trailer Court El •• Motel ❑ -,Other--::------ ---------- ------------= --=--- ] .fid ' x_ o'zJ s Number of living units:____- .-________Number of bedrooms __------ Grinde,r. Size___--______________________________..___.-----z-----___._.- private Water Supply: Public System and name :;:::__'------------- -= � Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ' } Hardpan-_F-l. Adobe.❑ Fill Material._._-.---_If yes,type___'_________________ _ f' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ^ ermitte if public sewer is available within 200 feet,) �. - NEW INSTALLATION: (No septic td�i or seepage p� p P r � + - -----------Liquid Depth-'474V- PACKAGE TREATMENT [ ] SEPTIC TANK Size t �D .., .� No. Com a�tments---`--- ---------------------f .: l Capacity . -Q --:-Type Material_ _LNo. P 4 Distance to nearest:.Wel1._ Q- -------- --=- j- -- Foundation.-_- --- ------_ --Prop. L'ine__/_0 ------ --� ' ` Total Length.--- y--------------- , - _Len th of each line.- -._-- T LEACHING LINE No. of Lines- g r �JJJ � �ojy ----_- -- -----=-----�--- --------•-- w -- F D' Box peth Filter Material __ -TYPe Filter MaterialQ� Distance to nearest:Well�6x�'--------- Foundaton...�tO. -------•-- Property Line--------------------------------- SEEPAGE PIT Depth--al_ -----Diameter_._a --------Number----_-----------=------•--- Rock Filled Yes Nof❑ i . M. ..= t I 1 Rock Size.------ �/Z_IC_"3 Water Table Depth---- r�'----- - 51 ,,. e t rr 3 _foundation._ -------- ' Pro Line__ __ Distance to nearest: Well_A� -------- - - P' ' REPAIR/ADDITION (Prev. ___.Date.---------------------------------------- ---------------- .. ------t --- ) Sanitation•Permit#___._- ---. _ - -------- ---------- - - -------- - Septic Tank (Specify Requirements).......------: -_--------=-= _---------- _= ---- ------ ' ---------------- --------------------------- Disposal Field (Specify Requirements)-. _ __ '-__; ---------------------:----------- l - ----------- T � t.'-- --- --- ---------------------= `. ------ ---- -------- S A_______________________ _________________________________________________________________________________ _-------------------- I __-_ .-_.__ _. ____ _____ ________________ - 1 "' (D.raw.exist.ing and,required_add:ition-on-reverse_side) i 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 I signature certifies the following: "I certify that in the performance of'the work for which this permit is issued, 1-4hall not employ any person in such manner as to become ub'ect Workman's C mpensa -on laws of California." Signed, -�1-�- --------Own B --'--------- --=------------=-r'------------- ----------------- --- --- -----s _ T� _ . . -' _� (If.other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ., ------------------------- -- ----DATE -----------=- - --------- - ------- -------- -------- ------ - _ DIVISION OF LAND NUMBER------ ---------- ----- ------------------------- :�------•_-' ------=---- -----`-_-- --- -----`' ----- DATE 3' '•" �, - 4'� ' ---------------------------- ---------------------- ----- - - - ADDITIONAL COMMENTS- ---------- + - __- --------------__.y A-- -__._ _-_ _ ____ ------------ ----------______ _---____ ♦ - ____.--__.____ - - I• F � ' � . �---�--- — r ' s . --- - ------------------------------------ . Da- te.--0 -bY Final Ins ectl ---= / EH 1324 ~. . + SAN JOAQ IN LOCAL+HEALTH DISTRICT Fss 21677 REV. 7/7e 3M