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FOR OFFICE USE: FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT a1�7` -------- --- (Complete iPermit NQ..�...``- n Triplicate) ................................ - - ---- ----------- �.------.. . ---------------------- --- Date Issued t ........ 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 ith.County Ordinance No. 549 and existing Rules and Regulations: ` 2Y. JOB ADDRESS/LOCATI 1. f�� - CENSUS TRACT....--- _- ....... f - - .� �< __.y- .,�....�� _�.__ � -,.-.Phone- Owner's --------- ------ --- -------- ----- ----•--._..... -------- --.-.-•--- � . .r�.�� Cit C�1�4`t!I.�y? `�.#..........._Zip _' ... ' Address.�d _ 3 . _ ..--- Y ` License # Phone-- ----=------------------------- Contractor's Name----- w.! #�+ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer,Court ❑ _ 1 Motel ❑ Other.---'. (�.. t 5:`�L5.P- . - -?[ Number of living units:- ;.�;.•"---Number of bedrooms.._.�...Garbage Grinder'..-. -----Lal Size....`]-f -'--- = 11 Private ❑ Water Supply. Public'System and name------ ----------- ------- --. ... ..-- Character of soil to a depth of 3 feet: 'f Sand E] Silt dClay E] Peat ElSandy Loam ! Clay Loam ❑ ` Hardpan Adobe ❑ Fill Material _ ..: ....if yes, type------------------ .. (Plot plan, showing 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 2(30 feet,! V PACKAGE TREATMENT [ ] SEPTIC TANK Size... ..----•------ ---•-- - - f ' ---Liquid Depth91�- - nts... . Capacity - ---TYP- . ..... ark.---No. Compartme Distance to Well_ J1901 Well :.J190l;.... - - - -. --.-- ,-Foundation_-7�0- ---- - -- ..-Prop. Line..-49.............. .... - Length #;each line.: ..------ - Total. Length -1 :........ LEACHING LINE [ ] No. of Lines. - . g Depther Material'.. t- _... D' Box_t. ..Type Filter Material..- --- ....Fou dation 11t.��--- -: No Line......�. -.�......•._-... ---.. Distance,to nearest: Well ---- . , " -. -- Rock Filled Yes No ❑ SEEPAGE PIT [ ] p .L1 Depth - ��Diameter..',:� ------ �---Number ------------- 2.1.2. Rock Size------ ------ ------- ---------- Water Tabled!Depth-------------1Z{� ..., �r i .....Prop. Line._.Z�3...._.. Distance to nearest: Well. -,Z --- ,x T ) _ -------- `:............Date----•-----•-- _:.-. ._:.: r . .- REPAIR/ADDITION (Prev. Sanitation Permit#".".- ---------- -�� --� +_ - Septic Tank (Specify Requirements[ ..-- -- • - Disposal Field tSpecify Requirements)- ' "".--- ----------- --------------- •--- ---------- - .> � (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 Con Ordinances, State Laws, and Rules! and Regulations of the San Joaquin Local Health District. Home owner or licensed age nts Signature certifies the following: "I certify th in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom b•ect to Workmap>sAA ,Com ensation laws of California." L r --� -- .Owne Signed r �tU/Y'l1 ..:..... .Title.....- ------ ------------------- --------- ----•--------• ------. ----- ---- ------- -�- ; - (If other than owner) F R D ARTME T USE ONLY APPLICATION ACCEPTED BY-,--------- ---- w ----- lYi^. . ..-- ----- -------------- ------- ----DATE DATE..._.....':�. _�y..... ._....,._....--.... DIVISION OF LAND NUMBER............ ..... --------------- - -- - - -------- ............. ---- -------- ---- ADDITIONAL COMMENTS----------- ------- ----_-- ---------- -- .: t_ ------------- ------ ---- ----------- = --- ------------------....-..._.... ---.--------------------------- ----------- --- - - .. . - Date........ ---- I Final Inspection b Gam/--- ... ' ----- --------- - - F&5 21677 REV. 7/76 3M EN 13 24 SAN JOAQUIN L AL HEALTH DISTRICT