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FOR•OFFICE USE: a FOR OFFICE USE: PLICATION FOR SANITATION PERMIT ...................................................... Permit No..79._9/ ... (Complete in Triplicate) • Date Issued..a-/>-.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 co/mplia�ncceCwith Co my Ordinance No. 549 andel e_xi�sting Rules and Regulations: r JOB ADDRESS/LO�CATION...!ZJy.'F...Y.-. o�a'f....... . •. . ........'CENSUS TRACT ............................... f Owner's Name...Y1.... ....... .........................................Phone..ga5_6-. ..2�....... Address_.�2-. ..7..._. .�. :....�.�............. .....�. .. .... City... Zip-Q.S^c3.�.�f'.......... . .. ....... ........... - .. ....... . + . P ...............:. . . . . Contractor's Name ly`.. ... ...... . . . . . .................License #i�Z .. 2.Z:A.Phone. .��.�{3c..f.. Installation will serve: ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.............................................. j( Number of living units:.....f........Number of bedrooms........Garbage Grinder............Lot Size..././2-....�9<........................ . Water Supply: Public System and name............................................. . ............. ..............................................................Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material.. .........If yes, type................................ c„11 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) IC vailable within 200 feet,) NEW INSTALLATION Capacity tytick. o y e e- ,rt. 'permitted se ...................Liquid Depth ..............._......... P seepage P� P � // PACKAGE TREATMENT I ) SEPTIC TANK ] Size...J�d.....:. P // ` . T p No. Compartments. f..........._ Distance to nearest: Well----F4"i>. ............................Foundation..... ............Prop. Line...K ............... C LEACHING LINE [ ] No. of Lines.... . ........... Length of each line..,... .� Total Length ...x !�. ........................ S //... i/ ,,( / f..'. - .. ....... � .i 'D' Box.4......Type Filter Material/l-2..F�:-:•�---Depth Filter Material ............... ...................................... Distance to nearest: Well.... P--i..........Foundation.._..3.0-. ......._Property Line......Sri................... SEEPAGE PIT [ ) Depth................Diameter....................Number................................ Rock Filled Yes ❑ No ❑ Water Table'Depth .................>:- .:..... ` -............Rock Size................................................ Distance to nearest: Well..:.:,, ...._.................:........Foundation..........................Prop. Line........................... REPAIR/ADDITION (Prev, Sanitation Permit#.......:............................................. ate..............:...............................1 SepticTank (Specify Requirements).. - ........_......:.::........:..-----------------....-.......-........-----------------.....-_...........------------------------------ DisposalField (Specify Requirements)....:................. .....ti................... - ................ ........................----...-------.................................... .. .............. .................................... ......... ....-- ........._...........---_........-- ,.................... -----........................................................ ........... ...................................... . •.................................. :....... ..................------:......-- ......-_.................................................................... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this applicationand that the work 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 signature certifies the following: . - "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to becomg tubj�e/ct to/W�orkma.... ari s Compe�psa�ti�op lows •oaf-California." Signed.//.)(711X mi---- ,4, .v By......................................... .........................._.........................:.........Title...................................................................... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... .. ... ; . . .. .. ..... ........................DATE ..... ....... . DIVISIONOF LAND NUMBER.................V......... /L ........................ ............... . . . .........DATE................................................ ADDITIONALCOMMENTS.................................................................I........................ .............................................................. ..... ................................_..... -- --.......:.............. ...... ....,.,...................................................................................................... . ....... ......._. .... .................... .. ................ ... .......................... _.... ... ................. Final Inspection by:........ ....................... ...................-- Dat .... . .. .... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT rse 21677 REV.,I W