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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: i7Z(Complete in Triplicate) Permit N0, 4dO ---------------"-" This Permit Expires 1 Year From bate Issued Date Issued. _�J--_-- Application is hereby made to the Sa'n4Joagu.;n Loco! Health District or a permit to-construc-t and install the work herein described. This application is made in compliance w.i�thGun"ty;Otdir�ance�,No.54.9 acid"e'zisting Rules'and`Ragulations: h , ...- } JOB ADDRESSAOCATION-_ 4 �. V J ----- ------ -----------= ------CENSUS TRACT------=------- ------ Owner's Name------� -....... - - ---------- -------------------.;- ---- Address �� / City, Phone ------------------ _ � yJ Contractor's Name _. r..._ .r.. _ - -------- ------------- License # j /�'�n' Ph Zip will serve: # Residence ❑ q partment Hoiise.0 Commercial ❑ i;711r Caurt.❑ ! NuIMotel ❑ Other _- .-----a------ ----- ------ mbei-of living units:"_____- __ v g Water Supply: Publics stem and nameer-of,bedrooms -- -----Garbo eGrinder--,:______`.Lot Size i ff p: ^ t Character of soil to a depth of 3 feet: Sand ❑ '.Silt 'ClayPrivate +• . Hardpan ❑ Adobe ❑ ❑ Y �❑ Clay Loa Fill Material_..___.-_-._ff es, t `r ' ❑ Peat type h t ! {Plot plan, showing size of lot, location of system in.relation to.welis, buildings, etc. must bei placed on neon reverse side,] ` NEW MSTALLATION:" {No septic tank or seepages pit permitted if public sewer is available within-2QQ-#eet;J� � PACKAGE TREATMENT [ ] SEPTIC TANK' [' Size_." Liquid Depth--.-7 Capacity. f -QD" Type-. N � ----------- - = = Material - _ ' �y . -= "- =-- o Compartments_."__�_ ; • Distance to nearest: Well----- �0-_- ! = :Fo undatior.n"" "�--..------- Prop. Line-.,-.--- ---------- LEACHING LEACHING LINE [ ] No, of Lines----_ i ---- - - Length of each fine..----I-_- I " ..: Tot Length.-J. alrS- D' Box---- - _----Type Filter Material.-__-______" -"--.Depth Filter Mater:ial- ----------------- Distance to nearest: Welt___"" .. .-" --" Foundation" _. ropert-y-Line SEEPAGE PIT --- - ---�--- t l Depth. "J(/ax it meter_ r . i6 P R k Filled Yes No Water Table Depth.---------- -""-- " - � Roc 'S { f{ • - --"----- h -----I-"" -------------------------------- t Distance to nearest: Well."- Foundation- -- - ize" .� ----�"_ . Pro Lln !� J = pr REPAIR/ADDITION (Prev. Sanitation Permit# :E_:-_-_"___- i hl� --------"------ - ,. Date - -- Septic Tank [Specify Requirements]_ _.__ --------- ----------------------- -------=---=------- -----------=-- _--- Disposal Field [Specify Requirements]-------------------------- -------------------------------- ----- ---------------- - - -(Draw ex-stin and required'addi ---- "-- -------- gtion on reverse side) 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 licens Sig-nature certifies the following: ed agents sig "I certify that in the performance 'of'the work for which this permit is issued 'I'shall not employ ari' ' to become subject to Workman's Compensation laws of California." r ' P Y Y person in such manner as Signed_-"-._ l ► I -- -.- -- ------ ----Owner BY - ------------------------------------------------- - If other than`owner] f _ - - l oil FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- 0. ---------- r ` = DATFDIVISION OF LAND NUMBER.--- - --- - --- - - -----.` -------------- DATEADDITIONAL COMMENTS--- -------- --.------------------------------------ -------- =-------------- ---- ------------------ ------------------------------------------ ----------------------------------------------------------------- - Finpf Inspection-b LL --------------------------------------------------- ----------- ---- P Y- - -------- - ---- ___ �t - - - - -- ------Date-r ----- -��7 ----------------------------- - - -- -- - - ---------- ------------- EH !3 24 ------ SAN JOAQUIN LOCAL HEALTH DISTRICT Eos 21677 REV. 7176 3M