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t� FOR OFFICE USE: FOR OFFICE USE: r Y4APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.'F-r-.q--5- ---------------------------- ------------------------------ ----------------------- This Permit Expires 1 Year From Date Issued Date lssued_l4_=1 _-�� 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 and Regulations: JOB ADDRESS/LOCATION....... , :;------- ---- ---- _ ' -- - - ---------- ------------ -------------CENSUS TRACT ---------------- --------_- Owner's Name. -e-�- 1�(.+�:�-.� r ------- —-=---------- -------------------- Phone- Address-------------- --- ----- `_e--- !` �� L Cifiy" �_ h - - _Zip-- P-� - - .tel Contractor's Name_ -----Q I J®t �J :� ► 3 - -------- --- - --- ------License #_��i `�- �1 Phone---V-//-T�Q_ V. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ' } .Motel -❑ Other----------- ----------------- - Number of living units:_.._.---../-------Number of bedrooms-._3_,.--Garbage Grinder-ft...'-Lot Size------ ------ e?.rv— -- --------- --------- Water Supply: Public System and name----'------------------------ _ ---------Private Character of soilto a depth of 3 feet: Sand ❑ Silt(] Clay ❑ Peat ❑ Sandy Loam ❑ Clay. Loam . d Hardpan ❑ Adobe Fill Material------------ yes, type________________________________ (Plot plan, showing ' JS size of lot, 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 is available within 200 feet,) PACKAGE TREATMENT [ ] ' SEPTIC TANK [ ]." . Size------------------------------------ ----------------------Liquid Depth ------------------- ----- Capacity-------:-----------jType------------=-----= Material - No. Compartments ----------------- f * ... 'Distance to nearest: Well------------------- -----------------------Foundation--•- -------------- ---Prop. Line---------------------- 1)_� , LEACHING LINE [ :I No. of Lines----------------- ------Length of each line------------------------------Total Length ----------------------------------------- ' + 'D' Box------------Type Filter Material---------------,_._---Depth Filter Material----------------- -- _I + Distance to nearest: Well_ _____________' `_----_Foundation---=--___-_-----------------Property Line------------------------------- SEEPAGE __ _----------"_-______--SEEPAGE PIT [ ] Depth----`-----------Diameter-'-------------'----Number---_---------------------------- Rock Filled Yes ❑ No ❑ t Water Table Dep'th-- ------- --------------------- ------------------------Rock Size- - - -Distance -Distance to nearest`Well_ -- ----------- ------------------- Foundation----- --- ---------- --.Prop, Line.--------------------- '- f (tic DDITION (Prev. Sanitation Permit#__ ____________ _ - --"_____-__ _______- -.Date___._--.--____-------___-----_----------Tank {Specify Requirements)_-.--------------------- - -------------------------- � --------------------- Disposal Field(Specify Requirements)--------------- "__- ------- x -------- --------- ----------------------------- hereby-certify that I have prepared thsexisting and that work - -- (Draw q tion on reverse side) � # _ k 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- w: signature certifies the following: *� "! certify that in tW pe ormance of'the work for which this permit is issued, I shall not employ any person in such manner as to become subi kman y mpensation' laws of California." 4 Signed ---- --- --Owner s By--`----4:------ ---- . ._ -- ------.--------Title-------- ------------ ---------------- -- ---- --- -------- ----------- (If other than owner) lit 1 R DEPARTMENT SE ONLY { APPLICATION ACCEPTED DATE ------- ------- DIVISION -- -------- - --------------- DIVISION OF LAND NUMBER.. - ---- ---------------- DATE . -- -----=-- --------------- --ADDITIONAL .- COMMENTS------------------------------------------------------ ----------- -------------------------------- E ------------------------------------- -- -------------------- Final Inspection by:-----. ---------- --------- ------------ --- bate/0__ J ------ - EH 13 24 S JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 776 3u