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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT b L � (Complete in Triplicate) Permit No--- ------:-------_ �5=77 -------- -- This Permit Expires 1 Year From Date Issued Date Issued.__:___--------- Application is hereby made to the San JoaqurniLotalcHealth District-for a4permit to-tonstruc�and install the work herein described, This application is made in compliance with County Ordinanc No. 549 and existing Rules and Regulations: p a / JOB ADDRESS/LOCATION ..-_ -_ � F_ -------- .CENSUS TRAC Owner's Name- Phone- ------------------------------- Address- hone Address---- ---- � - _- ----•- ,,,,¢_ Zip CityCLGG��4� # Contractor's Name-_: -- ' ' ,,_e ; � - ��~License_#.Z.S'y� S� __-Phone---- Installatiori.will serve: a Residence Apar`t ent House 0 Commercial Lj] /Trailer Court ❑ i Number - unrts..- ��, : _Nurri� � Motel-[]- of livin -:Other g r ber.of.bedrobms'.-w___Garbage Griner ------------1Lot,Size.-_ a- -e-g_ __-__--„__-_;----__+___ Water Supply: Public System arid:name- # ? - r r :.-: :: ' .- . . -------------Private Character of soil to a depth of 3:—t: ` Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy�Loam Clay Lopm ❑ L# ► 4, . Y Hard an.� . . 1 p ❑ ' Adobe 0 Fill Material_- If yes, type------------ ------------- (Plot plan, showing'size of lot, location ofisystem in relation to:wells, buildings,'etc-.must be'placed on reverse side.) NEW INSTALLATION:'” '(No septic tank 'o r seepagdlpit-,permitted if public sewer isavailable within 200 feet,) # PACKAGE TREATMENT [ ] ; SEI?TEC TANK i � 1 00 . 1 I 'r Size-_.-. `- .__ i ; [ I `�� --:--- Liquid Depth. - Capacity: - -----.Material y..-, f _ #No`--ompa'rtments_ ] ---- ----- ----- Distance.to nearest:flNell - : .I ----- Foundati -Prop Line-. LEACHING LINE (z] No, of Lines-:- I __ ---- Length of each line.---:- ;-F-: Total Lenth ------------------ ------------- :.'D Box-__--_- -- Type Filter kafeTiu - -- Depth Filter,MateriaL--------------------------- ^ "' Distance to nearest. Well '______ Foundation ___ ----- Property Line--- - ------- ----- SEEPAGE PIT [ ] Depth p Diameter---_- Number...----------------------------- t Rock Filled Yes ❑ No;E� Water. Table,Dep'th---- - ---Rock Size �. "Distance to neo est: 1Nelf _--__ --_ -_____ Founda�n. --_ Prop. Line . �p ---i_ REPAIR/ADDITION (Prev.!Sanitation-P( mitts#------ ---_- ~ -- Date__ "_ ,•_____ Septic Tank (Specify Requirements)__ -._x�w�._ �l�• r� -- - -� _ l .�._ r ------- Dispos Field ( p ify R quir-ementsli ' -- ---•--- --- ---- ----------------- _- [ ----;-------------------------------- h ; I' ------------------------- -• h k (Draw existing and required addition on reverse side) ' I hereby certify that'l have-prepared this application and 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 fo owing: ? ` >I "1 certify that in the p rP rmance 'of th work for which this permit is issued, 1 shall not employ a. person in such mariner has to becomeA b�ect orkman's Co ensatian aws of California." d f , Signed------- -- 11 ---------- ----------------------------- BY-; e - - (If other than'?owriet] .- r .-_.f: itle t - s FOR,DEPARTMENT-USE ONLY APPLICATION ACCEPTED-BY----- --i- -. - - - -------- ---------- ---- ------=-------------- DATE-.'--�---��-- ��j---..=------ DIVISION OF LAND NUMBER ------=--------------------------------° = = - .DATE ADDITIONAL COMMENTS-----=----------------------- ------ ------.--------------=---------------------------------- ------ _ --------------------------- -------------------------------------------- --------- ------------------------------------------------------------------------------------------ --- = --,- --. Final In _ ----------------------------------------------- ---- ----------- spection by.-- _ ..�� _ ---- -- ---Date.-- .- �- EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7176 3M