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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Corn� leate in Triplicate) Permit No._p ------------------ --- -- - : �---- ----------- • � .:� . �..r•-'..,� Date Issued_.13-- ------------------ -------------------------------- Tlfls Permit Expires I 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 Ordin nce, No. 549 and existing Rules and Regulations: s JOB ADDRESS/LOC ON.-:.:`-: �©a _ ----- ------ CEN TR �_- . _ ACT ------•-------- -- Owner's Name------ --- --- ---- 3 r µ. -- - ---------- hone._9_ . Address.-_ ? Cit_.- � _ :---------- a' rG ' ----- Zip P Contractor's Name_ ---------f' -------------- - 7�5�q p�o t . a = License #_ / Phone__/_. Installation will serve: Residence 0f partment House ❑ Commercial Ej Trailer Court ❑ ---------- - --- .. . - Motel [] Other------ _ Number of livingunits:_ t Garbage Grindea_ i of Size �l.S .��` S -_ _.__Number of bedrooms__ -- -- r Water Supply: Public System and-name --- t - -------`--- -----------------Private Character of soil to a depth of 3 feet: Sand ❑ �p ❑ ❑ :Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hard FEAdobe 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: `{No,.septic'tank for seepage pit permitted if public sewer is ovailp_ble within 200 feet,) PACKAGE TREATMENT ( ] SEPTICr ! TANK Size- __� - --L-iquid=Depth y - � _ /--- ------- --- :. Ca acit /: R_41b ---TYp-_----�--- -- --r----------M-i_-aterial. y�r _ NFo. Compartments--:partments--__ -----9Z ----------- YL nC _'---- ---,Prop. Lin -----Well _Fou -- e _ c .'I Distance LEACHENGLINE. j No. of Lines_ enthof each___-__ _.___. g --------- --VO---.Total Length._.._/_ e?U _. D' Box__'---------Type Filter Material ss- l-d----c- �_..D..,epth Filter Material--- /-- --- --- - [ i Distance to Well nearest: _--_ �_ ¢- :Foundation_____rp_ __.__- __..Pro ert Line._, r p Y t1-- SEEPAGE PIT [ De th__ S _.Diameter_ __- __-_____:___. ____-_ Rock Filled Yes No P :-. . �p k �� Water Tables'Depth-- _Q_Q.__-_ --- --__-{ '----.Rock Size.__- -- , [ r� t --=------------------- r Distance fio nearest:Well___.: } ---------_Foundation F,_ _.._..______ Prop. Lin --- j__R REPAIR/ADDITION (Prev. Sanitation Permit#________ t i ---------- ---:Date. ` ------------- Septic Tank (Specify Requirements)--:,------------- '° I ------------- - ' - ------------------------------------ Disposal Field (Specify Requirements):_____._.,.___;.__ _-- -- °` j $ t ----------------- ----- = - -------- I - ---------------------------------------------------- -- - --------------------------------- --------+----- ------------------ --------------------------------------------------- { [Dr'aw existing and required addition'on reverse side) I hereby•certify that I hoye 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 Sari Joaquin Local Health District, Home owner or licensed agents signature certifies'the following: . a "I cf:rtify that in the performcfhce--of`.the work-fog which this perm144' issued, I shall not employ any person in such -manner as to becomejec to W%dcinan's Compensation= laws of California." I / (//��//�J Signed / a ------- - i . .._, ------ ---------- - - --- s BY •��' -- - - --- i tle- - . y . F (if of er than. - .owner) ;FOR.DEPARTMENT USE ONLY r t APPLICATION ACCEPTED B -- --- ---- -------- ----- --------------- -------------------- ---=-- -------DATE.--/Z-+-X-P''- T_ ---------- DIVISION _.. OF LAND NUMBER--------------------------------------_- __ ----------- DA -- -- - ADDITIONAL COMMENTS-------------------- ------------------ --------------------- - -------- _._-_�________________________ __- r _ - .. _ -------- - -- -._Y-__ -------------------__ Final Inspection by - R Dat-e-.-------3_ [ `-- �- = " 1s 2a SAN J AQUIN LOCAL HEALTH DISTRICT Fess 21677 REV. 776 inn