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7 FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- -- --------------------- p-- . {Complete in Triplicate) -- Dafe. lssued_"r `.��. d ________________ ----------------------------------- 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 County Ordinance No. 549 and existing Rules a d Regulations: JOB ADDRESS/LOCATION_ .........D.. ---------------- --------------- --------------' ----,:---.CENSUS TRACT - Owner's Name./ i. .: ---- =-- --- --- e a 33 �r_�5. Address' ----- - =City / - -0 Zi .3 73 � � --- --------------------- y~ --------- - ---_ ... Contractor's Name__.___ __.. __ . ______�. :_ +_ . i + ens Phone k. - -------.License #--_�_�_-7/-S'.3 9, - --��'(��: ----------------- Installation,will serve:; Residence Apartment House❑ Commercial ❑ -Trailer Court ❑ NuY : Motel-D Other ---------=--- ---------------- ; Number of living units:--' of.bedroom s---- __-Garboge Grinder.----_--- -Lot Size____o��_---------------------- ----------------- Water -----_-_-.Water Supply: Publ is System and name_---;- -:- '" - ----- ---- -- --- ---- ---Private • - .I Character of soil to a depth of 3.feet: ; Sand ❑ 'Silt❑i Clay F1 Peat❑ any Loam Clay Loam ❑ a Hard�an'❑ Adobe Fill Material_- '`_ If es, t �p # __ Y Ype- ' --- ---------------- i [Plot plan, showing'size of lot, location of:system in relation to.wells, buildings, etc. must be placed on reverse side.] T ' NEW INSTALLATION: ;(No{-septic'ta'nk"or-seepage pit permitted if public sewer is available within 200 feet,) t [ PACKAGE TREATMENT [ ] SEPTIC TANK ['] t Size---- ------------------------------------------------------ Depth.------------------- - � Capacity ---=-------- -Type-----= -------------Material---------- - - -- - ------No. Compartments----------------------------------- ------=-----------------------3 fi s # .5,..,.,r„Distance-#o:nearest:,Well..,_...._ #�.-.�-..-��._.r «._._=Foundation_________-----___------___Prop. Line----------- LEACHING LINENo.No. of Lines.---- -------- Length of each line--------------------------------Tota l Length._---------------------- ------------_-Vl , } 'D' Box_.:------___Type Filter Material'_._____._________.Depth Filter Material-_ _______•- t { .... __ ---- ----------- -------------- } Distance to nearest: Well_-------------:------------Foundation-------------------------___Property Line------------------------______ SEEPAGE PIT [j i Depth----------------_Diameter____-_-- ---a_ _-Number___'._____________._ _ ------ Rock Filled 'Yes ❑ Noi WaterTdble,Depth--- =-----------'------------ ---- --.Rock Size------`-------------,-------- ----------------- t. Distance1to'nearest: Weil- ------------------------------Foundation---- ---------------- --- Prop. Line---------------------------- EPAI ADbIT ONs(P�ev. Sanitation Permit# = _ Date----------------------------------------- I ] k Se Tank (Specify Requirements).-=-- -- i------------------------- = ---------------- Disposal Field(Specify Requirements) '-A ---- 2 I ------------ -- ----------k- `----- , ---- --------------------------------- ------—-------------------- --------------------------}-:------------------------------ ----- -- ,� (Draw existing and required addition 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 tY Ordinances, State I Laws, and'Rules and Regulations of the; San Joaquin Local Health District. Home owner or licensed agents n signature certifies the following--:1' "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom ject to an'soCompensation laws of California." Signed- --- --------- ------------------ - -�'---_-- ---- -'Owner By - = ----------- � 7 jc:�� Title--- ------ -- ------- -------------- -------- --- k (If other thanowner) `• t 1 FOR DEPARTMENT USE ONLY'"" APPLICATION ACCEPTED BY_._ DATE. DIVISION OF LAND NUMBE `� DATE_.___-____ ------ ----------------------------------------=----- ---------------------- -------- ---- ------------- -- - ------ - ADDITIONAL COMMENTS---------------------- -------------------------------------------- - ------------------------------------.----- : = _ ---- : --- ---- -------------------------------- -------- --=------------ - = ----------- -- ------ Final -Ins ection•b P YU- ----------=-------------- -Date- k:N 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas zidn Rev. �i�b sin