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u 5L FOR OFFICE USE: FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT ------------------------------------------------------ Permit No.27-�3.6 (Complete in Triplicate) ��--� � � � • ----------------------------------------- --------------- t �-�'�"�1 `��r C••- c �� " t bate issued=2�-�-This Permit Expires 1 Year From Date issued i 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.-------------�r----2---- TE'CZ -------------------------- CENSUS.TRACT------T- ------ ------- r Owner's Name e 'M- N-------- -------- --Phone-- �/o --------------- --------------- -------- ----- t , Address ------ - -- . L G - ----_-- - ---_--- City-- Y , ;-----------Zip-. --G----- 2 .-----------`------- k..t� Contractor's Name- .----- -1 %.. ` License # 2 / �' �_.Phone `Em T Installation will serve: € Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ MotelOth --w ----- ------Number of.bedrooms---3-----er------------------------ -------•------------- Number of living units:.__ f ❑ ;___Gl rbage Grinder--- -__Lot Size.:___ l�.z f Water Supply: Public Sys#em and name--- ---------------------------------- -------------- -------------------- Private's J"� Lam. Character of soil to a-de P th of 3 feet: ' Sand [ Silt❑ Cfay ❑ Peat ❑ Sandy L o�❑ Clay Loam ❑ ('T 0 . Hardpan ❑ Adobe ]i Fill Mate rial------------If yes, type---------------- ___ __ __ : 1_ (Plot plan, showing size of lot, location of system in relation to well's, buildings, etc, must be placed on reverse side.) NEW INSTALLATI'O'N; [(No,septic tank or seepage-pit-permitted if ublic sewer is available within 200 feet,) ii 0 er PACKAGE TREATMENT [ ] : SEPTIC TANK [ J Size________--_.__________ __X_______�_________Liquid Depth.___y_ -_�____'.__ Capacity.__ _ _.___Type___ z ^_MateriaE_._. �` G'`` No. Compartments ------------------ 66 Distance to nearest: Well. _________.` _______________________Foundation_________________-____.Prop. Line-, __._.__.__.__ -_ LEACHING LINE [ ] No. of Lines Le of each line Length _.------��L?-----._:__,_ 4 1- ., D' Boz.____/__:--Type Filter Material..__1_r/Z__f`+.Dept.h;Filter Material----------------_---.--------------- � � "' � � . - i � � ----- ----.Property Line ------�J-- ------------------------ • tDistancatdn�are�t: Wel!___.__ /_�_�__' Foundation.__-__.�__ . "Depth EJ SEEPAGE PIT [ J Water---able•Debia thmete r,r, '. -Number_-- -- ---Rock } Rock Filled Yes ❑ No € P - . Size------------------------------------------------ Distance.to nea est: Well--'---------------------------------------------------------Foundation----------------- `- Prop. Line--------_-----------------. REPAIR/ADDITION (Prev:Sanitation Permit#---- ----------------------------------------------Date---------------.----------=-------------------) Septic Tank (Specify Requirefnents)----------'.. ------ .�-- ------------=----------------------------------------------------------- =-----=-------- --------------- ------------- - Disposal Field (specify 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 County Ordinances, State Laws, and Rules a�d 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-far which this permit is issued, I shall not employ any person in such manner as to become subject to }Workman's Cornpe ation, laws of California." Signed . s } - _ ---------------------------- ----Owner ._ BY s - ;, y Title (If other than ner)' F0 RVEPART NT SE ONLY APPLICATION ACCEPTED BY------------- ---- -- -- - ------- ---- ---- - ---/- - - -------------_DATE._-.-__..S_ ------ DIVISION OF LAND NUMBER.___-----__-----_----__ DATE_ _____.___-----___ ___ . . ADDITIONALCOMMENTS-- ------------------------------------------------------- --------------------------------------------------------- ----------------------------------------- --- t -------------------------------- ----------------------------------------------------------------------'=---=----------------------------------------- ------------------------- ---------------------------------------(------- ----- ---------------- ------- ----- --------------------------------- ----- ---------- -------------------- Final Inspection by:-.: } ��,..�. ---: _ _- - ----------------------------------------------------------- - - -�------------Date- EH _ = - -------- ------------------------------------ Py:-------- =- = = _ ' = ate �-- -- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21577 REV_7n6 Sea v I�