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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------ - - Permit No.,781__2-S - - - � I�--- - (Complete in Triplicate) `---------- ---- ---------------- ----------- � Date Issued_.f_-7:577:2_e --__________________________________I�....__ This Permit Expires l Year From Date Issued c 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 co pliance with County Ordinance No. 549 and existing Rules and Regulations: t _ J08 ADDRESS/LOCATION 0�- _,. ' C �l�_�......'----- - ----------CENSUS .TRACT-- -- ----------- -------- �::::- - 15 Owner's Name-- �= - leG..;: ------------- ---------------------------------------------------------Phone- Ef �-4 - F Address- ---- ---- - -'.- = :. Y /P�Yf2, ' :Cit �r Zip- --- 1 Contra ctor's Name__.- is� l.�� -----•- ----•-- - -- License #r�? -til Phone j- .� �®. k lnstalla ion willsere`a 'a Residence ❑:. Apartment House❑ Commercial E] Trailer Court ❑ E ] .`"' E .Motel (] Other----VA 149-4 ------=------- --- i F e g ___-Number of bedrooms--_.__ Garbage Grinder.___ =_Lot Size------- -------------- f-- Numbe of livin units:.___ Water Supply: Public System,&d name___.,_ - '-: - = _ `--_, ----------------------------------------- ---------Private Character of soil to a`c7epth of'3 feet: Sand-] Silt ❑ Clay ❑ . Peat ❑ Sandy Loam ❑ Clay Loam }} ,�Hard'pan ❑ Adobe❑ Fill Material_.._.__.-.--If yes, type________________________________ (Plot plan, showirrg-size of"Iof, location of system in relation to wells, buildings,.etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer wer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------ ---------------:--=------'--=-- ----Liquid Depth t& &----------------:. ��{{,,� � p s C..a.pC3 cit Y cam'-' TYPef` elr� ----------------- =-----No. Compartments--- --- # �' f 1 Distance to nearest: Well._��--------------- jFoundation_��---.�---...------.Prop. Line- -----: _--.---- LEACHING LINE [-]-�-No. of Lines_. _ -------------------- Length of each line..- Total Length.__ �s?_ �_ _•._.--- LEA 'D' Box. - Type Filter Material 14 4- ;-_ epth Filter Material__`----Al-___----- ---------- -- -. Distance to nearest: Well ___.__._______._Foundation__�¢ __..Property L =7��-�� `- Y i ° Rock Filled PIT Depth----------- --- Diameter---- ---- ___Numer--- -----=-----=------ ---- �Y--e-s [:j No E]Waer Table Depth-------------- -------------------- ---,-------- Rock Size-'-----------------------------------------t .. k Distance to nearest: Well-------------------------------- Foundation-..__.----.--------- ---.Prop. Line.----------------------- -- REPAIR/ADDITION (Prev. Sanitation Permit#- - '- - -Date------------ --------------------------- -----) { �M -. -------------------- - ------------------ ------------------- -=- --- ------ SeP✓ Tank (Specify Requirements)------�r =-- ------- --- --- ------ --------� •• Disposal Field (Specify-Requirements)_ --------------- --------------------------------------------- ------------ ------------------------------------------.- ---------- ---- t -- ----- ---- �!_ - - -----------=-------------------------------------------- ---------------------- --- --- -- ---- -- ---------- ---- ----- ------- ---- ------ - ; (Draw existing and P.equired addition.on reverse side) 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 signature certifies the following: "! iertify that in th`e performance of"the work for which this perriiit is issued, .I shall not employ dny person in such manner as ---------- Sig' i nedo_e, _ - -�a,�,of Califor`nid�'' ,. .. . to become sub'ect ro. W an's Com -ensgtioa. law s� �L� - per__. _._.._ - g ' Owner r c. .. I3 \ <wi z C`•_`+� � - I �Title - -- -------------- ----- --- -- BY = ------ --------------------- j5;(1f other'than owner) s } - . `"'. Y... .. -JOR #.. DEPARTMENT SE ONLY APPLICAT.ICN ACZGEPTE-D-BY -DATE.----_- _-3---(- - --r DIVISION OF-LAND-NUMBER -- _-- :- '_` -- -- - --- '..---- ---.DATE --- ------- . ------------------ .. - ADDITIONAt�C-OMMENTS-:- ._ _ - �-- -s--- - ----- -• - ---- ------ - .�. : ► f - = --- ----- ----- �. --------------- -- f = c - - --- - --- --. - ---: �._ _. _. � `"-------- ------- ----- -'i-- -- -- -- � Final inspectionbY° , :._ __ Date _ . wry � - EH 13 24 �v SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7176 inn