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FOR OFFICE USE: ., A4,A ) LL' � FOR OFFICE USE: }-� APPLICATION FOR SAINITATION PERMIT FEZ, d7iwfs ........... - ----- .. �� (Complete in Triplicate) 16�1� L No...____--------------- -----------------------------6 ate Issued--�, =�'��__.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 plication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: A JOB ADDRESS/LOCATION 7/ �Tma CENSUS TRACT Owner's Name.- l.C ' 12.@--- -- j------- --------------- -- -------------------------- ----------------------- -Phone.--.9.P :-�0331 Address. (a.9, '..-.X.P- /J-C-------- Aeo-.5vA------------------------ ----city--6.S'C.9oc0-A"--------- ------ ~7 -------- Contractor's Name----------- - -- ----------------------------------- -------------License #.--------------------------Phone------------------------ Installation will serve: Residence EK Apartment House.[-] Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------- Number of living units:---.--�.t_.--_Number of bedrooms----�-,.-Garbage Grinder--./-----Lot Size_--,00es"-J�_-*07-�--------------- -----I--- WaterSupply: Public System and name-------------------------------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Sift ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam l4ardpan ❑ Adobe ❑ Fill Material.____-----__If yes, type------------------- .__-__----- (Plot plan, showing size of lot, location of system inrelafion to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLA71ON: (No septic tank or seepage;pit permitted if public?sewear is vailable within 200 feet,) PACKAGE TREATMENT K" I Size-----. r1 -----------------------------Liquid Depth.--------------------____-- Capacity PSC � ' G -----Material T i Type - r iso. Compartments ------- ----- o Distance to nearest: Well.---/g�-—------- Y- __-___-_Foundation__-1-D---------------Prop. Line----l_/�_-.-----_----_.q� LEACHING LINE ( ] No. of Lines-----Z---------------------Length of each line------e, -_--________-__-Total Length _______ __`__----.--____-_----.-- 'D' Box------------Type Filter Matehal--------------------Depth Filter Material-------------------------------------------------------------_. Distance to nearest; Wells-. -� 135 __-Foundation.----amu!_________________.Property Line-.A00<-,- ------------------- 'Q SE AGE-OT Depth---f n--------Diameter_:_ _- ' " -- ------Number-------Z�---------------- ----- Rock Filled Yes No ❑ Water Table Depth----�;?------=-------` -----------------Rock Size-- Z ------------------------- 1'X FX /Q Distance to nearest: Well_ .a --------- -----------------Foundation---_.-7'r-_ -- -------- -- Prop. Line--- -$7 ----------- REPAIR/ADDITION (Prev. Sanitation Permit#------ s-----°_________�____ __________________Date.--.--________.______________.._ Septic Tank (Specify Requirements)___________________ Disposal Field (Specify Requirements).-------- -- ------ --� _IV- -------- {- � -------------------------------- ------------------------ --------------------------------------------------------------------------------------------- ------------ ----- �X r ---------------------------------- ----------------------- ----------------------------------- ----------------------------------------------------------------------------------------- -------------- (Draw existing and required addition on reverse side) .S I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Com unty 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, I shall not employ any person in such manner as to become bject o Workman's Com nsation laws of Califo ' . Signed---_ . By--------- ---------------------------------- ------------------------------ ---------Title.------------------ ----- ------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY- ------------------------------------------------------ DATE. - " . g ------- DIVISIONOF LAND NUMBER-------------- --- ---------------------- ------- --------------------------------------------------------.DATE----------------------------- ADDITIONAL COMMENTS-------------- --- --------------------------------------------------- , ---------------------- --------------------- ------------------------------- ------------------------------- ---------------------------------I----------------------------------------- ---------------- -----------------------------------------------------------------------------=------------------ ...... --- ---- ------�f ---------- �` --------------- Final Inspection by:-.------ . ._ -------------------------------Date--- -------7------------------------- EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M .