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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ; (Complete in Triplicate) Permit No.__._._____-..--_-_ -------------------- ----------------------- gate Issued._. � _.-7 - v -- - - ----•. _This_Pecmit.Expires 1 Year_From-Date-Issued Application is hereby made to the San Joaquin Local Health'Distr`ict 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: t - N - ----. --JOB ADDRESS/ OCATIO % O - Z '- . f FCENSUS hoTnRe A ---------- wrier Name _RQ_RY-- LTT.4.�/f ` ------ --- -- z '/ Address------------------------- r_J4j' ./ ,�.. • ; - r...- city T _ --- --- ------ -------Z__� `pr�d --------------------- Contractor --Contractor's Name.------- ----License � Phone rKl� k� � Installation will serve:: Residence Apartment House.❑ ' Commercial ❑ Trailer Court ❑ : r ...... - Motel '❑ Other--- = ' • Number.of living units:_- _lf._____Number•of.bedrdoms:_-_rYGarbage Grinder=._.._... Lot.Size -r_ _ -- ` ------------------ . Water Supply. Public System and�name-------------- _- +� ,� M pp Y? , , .. :. -. -_ - -. -------------------Private ❑ 5 Character of so I to a epth of-3-feet: . Sand ❑ Silt❑ Cla Peat San i Y ❑ ❑' d Loam Clay LoamEj """'.Hardpan C].�. Adobe:❑i Fill Material- _ -If yesz (Plot plan, showing s� lo,� --- -- aYpe---�------� ----------- 1------- 1 iie�ot, ation of system;in relation fao"eIIs, buildings, etc.!must be 'placed on reverse side.) NEW INSTALLATION • (No sep$is tank or seepage ,pit permitted if-publisewer iss awaila0e with n'200 feet,) Ur PACKAGE TREATMENT- ["] .w SEPTIC TANK ['] Size____ quid D � - t Capacity ------R- ----..----- Type---- = 1 ! ---:_Material------------- ------------Nom. Compartments-- --•------- - - ------------ f ^pistance•to nearest: Weli•------------- -y-------------==------------Foundation------- - ----- ----Prop. Line--------------_-- _ i LEACHING LINE [ ] No, of Lines.i__- ____-- _.,_..'-_-__,Length of each line_------------_---_------------Total Length.._--_-___--______ :D' Box._`_.-_. __Type Filter Material_______ ______ -----Depth Filter Material._ -----_---------- ! -- --------- --------------------- Distance to nearest: Well-------- -----------------Foundation----------.i___-------_--_--.Property Line -------------- ----- :. SEEPAGE PIT--[ ) Depth--- --.-Diameter -�------ -----.-Number, ---- ----- -I�-- Rock Filled Yes ED No ❑ Water Table:De•pth--------- = ---- Rock Size-------= ------------------------- Dista rice to nearest:Well - Foundation-------- i_Prop. Line - x t ------ REPAIR/ADDITIONpyPregv:Sanitation P` rmit#- - ---------------------------------------- --------Date-------_----------------- - Se tic Tank S ecif Re uirementsJ__ ,-- -,d�{Q fto7 `F l _�....�r- �, , ---- - -- ----- --------- Dis osal Field {5 ecif Re uirements .--':___ ` p P Y q M s �- µ-. ) • � (Draw existing and required addition on reverse srde .- � - '• 1 hereby certify that I have prepared this-application and that the .work;will be done in-accordanceI with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health°District:,H,ome owner or licensed agents signature certifies the following: "F certify that in the performance"of`tlie work'for which this permit is issued, I shall not employ any; person in such manner as a to become sub[e Work an's pensati laws of. California." ] Signed_' Qwnpr :K..`F a --------- ---- -- _ Title-- (If itle(If other than owner) �_. .,FOR DEPARTMENT USE`ONLY— ' APPLICATION ACCEPTED 8Y-` .zt -------- I ,..DATE- - - `" 1 ------------------------- - DIVISION OF LAND NUMBER-------=------------------ -------------- �;; pA ------------------ _ ----------------------------'• E = ADDITIONAL COMMENTS- -------------- -------------- ----------- 1 - ----- ----------- -------------------- -------------------------------------------- -------------- ---------------- . T ---- --------- ----- - - - ----.__---- ----------------__ .------------- ------ - --- -- r - Final Inspection by:. ._ .,.. _-_ - --•--------- ------ ------ ------ ----- -Date --.... -� ---a`7 -�-�---'--- - EN 13 24 N JOAQUIN LOCAL HEALTH DISTRICT las 21677 REV. 7/76 am