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FOR OFFICE USE: ✓ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- ----- ------ ------------- ---- ---------- Permit No._7J�-,/f/----- (Complete in Triplicate) --- -------------- ------------------------------- Date _"---------- ----------- 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 Co my Ordinance No. 549 and existing Rules and Regulations_ ' - - - ----------------- SUS ACT= - JOB_AD.DRESS/-LOCATION _ ---- ' � -.Phone-- ---- �^7 �!.¢ ` Owner's Name__3lry w� Add e 7 (/� r ` - r -- .�- City -- - Zip f � I a r ss t Z -- ------------ r one Contractor's Name ------------------!License #� ---_ < `� �� Ph � -- - - -- _.� �� -_ sem- ��-�-�- -- �. .- . .�. ._ ..._ Installation will serve: Residence [K Apartment House Commercial .❑ Trailer Court❑ F a• Motel ❑ Other t -- i . ) IS 1, is Number of living units:._'__ Number of bedrooms_.___ -__Garb g Grinder' -___ Lot Size s1 2 -- � J-. - r Water Supply: Public System and name---- -:----.'-.-,--:-------�---.------ - Sand Lam = Clay Loam - Private.'� pP Y Y - '"" Character of soil to a depth of 3 feet: Sand ❑ "_Silt t]3._ Clay ❑ e Peat Q .. y :`� ❑ ._y. t ,. � f -- _--- - ---- :Hardpan ❑ Adobe,❑ = Fill Material-__- -----if yes, type_-_�._f 1 (Plot plan, showing size of lot, location of system in relation to wells;buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: !(No "septic tarik or seepage pit'permitted if uhlic sewer vailable within 200 feet,) PACKAGETREATMENT [ ] SEPT{ TANK ] Size.__ e �S `- ' Liquid Depth - --- - ---- - -- en -- - --- ------ -- I Capacity - ---- --:--- `TYPe = ._ = Mater1al .:- -No; Com partm _ -Y- // +____ Foundation. ._:_ -- ' _ -Prop. Line- - -------=--- Distance.to.nearest:.Well,-._. .___------------------- No. of Lines.`- :. ------- _----.Length of-each line; ��------ ------------Total Length1`� --- --- LEACHING LINE' 1: 1 - r, f �- - 'D' Box_o ___i-_Type Filter Material/�__ F ..Depth Filter Material_?-_� ____ -�--� - �-- b J �- -- 1 Distanco to nearest: Well--.--�-T-- -----: --- - ---•--'---Property Line------------------------------- �--t__Number ndation.=.___� � ' .. `-^-* •i € Rock Filled Yes No ❑ h. --- Diameter_-._ - ------ SEEPAGE E ❑ SEEPAGE PIT [ ] p "- ' „f r .. Water Table Q#h - '� -�-r�.,w.:.'+� _Rock Size;- ------------------------------- - . -- a 1 ' .} ------ - - Distance to nearest: Well._- Foundation_____- ____ ----Prop. Line_._ _ ` -- ------------------ REPAIR/ADDITION (Prey_ Sanitation Permit#----- -- ----------- - ate------------ -------------°------=------'-----) t ----------- ------J--- Septic Tank (Specify Requirements)-=-- , ---�--�---- -----=------ -------=�=------- --- - i ; I Disposal Field (Specify Requirements)-------- ------------- ----------------- -------------=----- ------------- J I , ----= ----- .._ ____ .______ _ _c_.._____ __S_ nf- ____ ____ _ • e. _ _ _ _ _______ .__-t_____ ____________ '7 g 3 (Draw exist n'g" and req'fired additio Fon reverse side) I hereby certify that'I have prepared4his',application and that the work will L be done ;in accordance with San Joaquin Cur., Orclinances,i State Laws, and Rules.an d Regulafions_�fof the San Joaquin Local Health District. Ho-me ner or licensed agents signature certifies the following: - 'r "I certify that in the perfbrmbnce--of the work fo-which this permit is issued, t shallno emp ey any person m such manner as to become ublect.to Workma s Compepsation la sof California." t e ,I�� Signed '- ,�J ------- = f --- I e t. d ------------------------ �4- ' -------- ____ iTitle -- - ?;-- (lf other than owner) 1 ' FOR'DEPARTM T USE ONLY. „ a ----------- APPLICATION ACCEPTER BY --- -- - - - D� f Tl .:_ '� . DIVISION OF LAND NUMBER:- -----_----- ---- F----�- -- �v----------=---------------- ----- ------------------------ C -------- =-------- -- DATE - = j ---------- -----------=-------- ----------------- ---------------------------------------------- 11 ----------:----- ------- ---- ' ADDITIONAL COMMENTS = t ` 1 ) --- --------------- -- ------ - -------------------- ---------- ------- --- '------------ ---------------------------------------------------- ____.__------------------------ ------------- _______________________ __- F __ _ _ __ _ ___________ ___________________________________________________________: --.y�}�/s�,-__--__ ------------ ------------------------------------------__ --_ D t.I Final Inspection,by;:-- EH ----- ----- ------- ---------------- -_ a -_ 00 P Y; - =- VIP �C EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REv. 3M f