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FOR OFFIC 5E: FOR OFFICE USE: --- APPLICATION FOR SANITATION PERMIT �/ ----------------� "k------------- (Complete in Triplicate) Permit No---?�-- --------------------------------------------------------- Date tissued. This Peirmit Expires,I Year F tom Date Issued ^-b, t s"� C 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. 54'9 and existing Rules and Regulations: * JOB ADDRESS/LO - ,,,--®S' N( "�'' -- - 'T;rra n� CENSUS TRACT ;; --- --------- 1L.W Name- _. ,rl � Phone :�Owner's Na '---�-- Address--- ------ �� f /?•� ,--- 4 t, Gi ZiP - iaTp- _ Contractor ss Name---- -nr--- -- �J � )41: _.+�._+�� - License#�:�4- ��----Phone--------- Installation Will serve: Residence,W Apartment,..Hou se 0 Commercial'❑ Trailer Court ❑ ! Motel Other :_ =-------------------------------- i Number ` 5 & -. Number of I ving units____ of.bedrooms'-- r__Gdrbag6.G�'i'der-� i -_lot)Size-- . `- ._-_ _ _-.__._ -___-----Water Supply: Public Sys and name -------------- -- - [_1.. - - nvate ❑ Loom , Character of:soil to a depth of 3 feet: Sand El Silt❑ Clay E] Peat__ Sandy Loarrii ) � I Hardpan ❑ ; Adiobeg, Fill M�a�erial� --- _.If yes, type --.-- # 1 ce�-on reverse side (Plot plan, showing size of lot, location oflsystem in relation to wells, buildings,.ec.:must be.p a e-) i NEW INSTALLATION;- ;(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) . Size _ ---- PACKAGE TREATMENT [-] SEPTIC TANK-'j'] p -_-- -------- cri� €De th # M MNo nti Capacity -- Type--- --- aailo patmes Y . i _.,_:. :w.Y-�. ..-- —round --- --- ---° --- 'Distance to nearest: Well_ - -- Prop. Line 1�- i LEACHING LINE [,] No, of Lines-___. . ''-__._: Length of ea€h line Total'Length-'- ,.._.___ __' ' D' Box------------Type Filter Material--------'------r-:--Depth Filter afierial---------- s-------- ------------------ [ .. !� . . .- ._ f j , Distance to nearest: Well._ ---.-_ ',—� Foundation_.._. Property Line_______ :- ti I SEEPAGE PIT [ ] p ----f----. '- { --N.um ber--------------#__----------=- 3 t Rock Filled Yes ❑ No De th Diameter ; ___. _._: 1 ` s Water Table Depth -- ------ :- Roe}iSize - 4 1- _Foundation :_.Pr Line.------------- Distance.to nearest: Well ----------------------------- ----------------- -- _ ---: - a Ap. - ) REPAIR/ADDITION (Prev. Sanitation Permit#----------------------- ,--------------_ - :-------------------------------k---- p Septic Tank[(Specify Requirements) r - - ------------ Disposal Field ( ecify Re uirem nts -------------- - �. is _---- L------------------------------- --------- =-- ----------- -------=-- ------------------ ---------------------------------------- i (Dr1aw existing and required addition on reverse side) € 4,. : % ;: I hereby certify that I have prepared this application and rtheh_at, work will 1be tidone••in_accordance with San .Joaquin County Ordinances,' State Laws, and Rules:andG Regulations of the San 'Joaquin Local H lea th 'District;•Home owner or licensed agents 4 signature certifies the following: i i g "I certify th1at in the performance �of,`the work for which this permit is issued, I shall not employ any person in (such manner as pen alio ;laws of California." , { to bec ee -su 'ecF ._Workman Co w t j € . 1 e ' ' ------1 r i �`� ! i ey � i BY--- --=------ = --- [ j a i ..; _ . �". other than owne�J � ! i 'I; t f FOR DEPARTMENT USE ONLY l E i F APPLICATION ACCEPTEDy"B'�" 2 '�,'�' :- - --- -- -} DATE. !`3 -' /r ` - --DATE 4 DIVISION OF LAND NUMBE_R-d ------ ----- = ADDITIONAL COMMENTSI-- ,— - ----------- 1------I --------------- -----------------�Y ----- - --- --- - T �' �f ) -_" ------- --- ----- -- -- " t ------------------- ---- i � - li: ...f I -- ---- ------ --------------- r` ---------------------------- ---------------------------------------------------------- - -------------ti--------------- - T Final Inspection by:�- �_ l r i — ---- - + _' ---- -------- ---------- ------ ----------- F ------- ------- --- srn ---------- --.--.Date: EH.to-24_ . SAN JOAQUIN LOCAL.HEALTH DISTRICT as 21677 REV, 7/