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FOR OFFICE USE: t� 4� FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT ----------- — 1D/. Permit No. _ S-.f 4 )' iCamplete in Triplicate} . 0-AC)A 2AT) 1t + ate issued./,-?.-/4':7,7$' --------------- ------------ _ _------_-----_---__------- 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 and Regulations: ' JOB ADDRESS/LOCATI; _ �+, _ ON.---- �{7-------- -� -1_�-�CZ�--------- ------------ - _ CENSUS TRACT--------•---------------- Q Owner's Name ' k ? ------------Phone- 212C1 yv� Z � CiAddress --- ------ -- -- ------ ---- ----��h{1�rt--- ---------------------------------- ------ tY-- za Zip - Contractor's Name-----T''�------ 2�rl� License - one �,� -G -y #_____ -- Installation:will serve- � Residence Apartment House.(�] Commercial ❑ Trailer Court ❑ Motel ❑ Other--------- --- ; Number of living units:-----)._.______Nuber of bedrooms_.__.___-Garb ge Grindar___._.__..-;1ot.Size._.._.___�_."� . rri ._ ".__. R�3 - Water Supply: Public System and name------------------ : ------- ---------------------------- -,----- `+,v --Private Character of soil to a depth of 3 feet: Sand � ,Silt ❑ -Clay ❑ _0tfd7176dM`'0" TClay Loam ❑ i ! Hardpan ❑ Adobe E] --Fill Material--_-- f"yes, type---- --------------------- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed oil reverse side.) NEW 1NSTALLATIO t (No`•sept�c tank or seepage O9kt ermoi ed if public sewer is available within 200 feet,) + C TANK [ ] e Ze --------- -Liquid Depth --------�--.--------- Ca acitY.___A �� PACKAGE TREAT T C p cit T'I' �O Type_- �--Material__.�e'n.�N�___.__ _No. Compartments__.- _- __._____-----------' �U� r Distance to neat: Wei ----------------------------Foundation-=-----------------" ---Pro Line. LEACHING LINE [ ] No. of Line _.__.____.___.Length of each line.-------------------------- „Total Length -----_2"1_a- 'D' B x__•A------Type Frlt,er Material- -Depth Filter Material-------------------------------- ---------------------- e Distnce to ne�rest: We I I-- v............Foundation-----------V -Property Line-----�-------------------------- SEEPAGE PIT Depth-------------I__Diameter---------_-----------Number-------------------------------- Rock Filled Yes ❑ No❑ Water Table Depth ---=---=---------- --------------------------- Rock Size ---------------------------- Distle to ne rest: Well--------------------- ----------------------Foundation--------------------------.Prop. Line------------------- REPAIR/ADDITION (Prev. San tation Permit#--- ----'-- -- -----------------------------Date---------------------------:-----------.------! i Ln ' t. Septic Tank (Specify Requirem ts].----- - j _ --------------------_-- Ln ---------- Field(Specify Requires entsl-- -_).---- ' = - ---------- .._. =------------------------------- -------- --- - --------- ----------------- ------•----------------------- --------------------------------------- ------------------------ ------------7------------------------q--------- --------- -- ------------- -------------------- - ------------------------------------------------------------------------------------ ------------------------- Draw ex sting and required addition on reverse side] ? hereby certify that I hLe prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,, State Law's, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: ; "I certify that in the performance of the work which this per is issued, I shall not employ any person in such manner as to become subject to Worklan's } - , Compensation laws of California. " Signed-- -�-------------- Own es Y ---------------------- (if - Title-- -- ----------------------- -------------------- (if z J other than owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. -- ---------------------------------------•-------------------------DATE ------------- ---- DIVISION OF LAND NUMBER = = ---- -- - -------- ----.DATE--------- --- ------ ,. ADDITIONALCOMMEN,TS----------------------------------------------------- -------------------- -------------------------- ------=------ ------------ ---- ---- ----------------------------- ------------------------------------- -------- ------ -- ---- ------------------------ ------- --------------------------------------- --------------------------------------------------------------------------- 1 ------------------------------------- ------------------------------ ------ ----- ---------------------- --------------------------------- --------- --------------------------------- ---- ---------- ------------ ----- - -- ----- l Final Inspection by:--: . __Date._'_ _ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 Sen