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FOR OFFICE USE: 10 1.3a_ L{ u -" APPLICATION FOR SANITATION PERMIT .. ..... -"- � - ---..... FOR OFFICE USE: • (Complete in Triplicate) LDate No.7g.- . .. This Permit Expires 1 Year From Date Issued ued. -", "? Application is hereby made to the San Joaquin Local health District for a permit to con struct and install the work herein describer This application is made in compliance with County Ordinance No. 549 and existin JOB ADDRESS/LOCATION_----.-.-.. . _.9 Rut es and Regulations: Owner's Name.._..... . f'ri �.lr_ tV.l .. .- -tJL"--`-"'' .�...CENSLI5 TRACT........ Address..- 4 � ti?.E!. � "....._.-- ,-- --------- --- .......... -------- -- -- -- - ----- -- --- ---------.... . ....-._.....-- -----�----Phone........------•-•........... ......... Contractor's Name ". ---.- ---.City... . , - -.e rL._.... ___ -- -- . p-------- ----- -- -------- Installation will serve; � �� v'- ,� .. -°k- !`! - -- .... .--� � - ��-- .License #..,�-�-- - � Residence ❑ Apartment House `�- Phone.- Commercial Motet ❑ M Trailer Court ❑ Number of living units:._....."-.. ❑ Other—.... - ------ umber of bedrooms-..._--... Garbage Grinder-.--------_Lot Size.- .... Water Supply: Public System and name.- ......... . .. Character of soil to a depth of 3 feet: Sand - •............. -- - -- . .Private �.. ❑ Silt �� -----------•-- - ❑ Clay -- Hardpan ❑ Adobe Y ❑ Peat[] Sandy Loam ❑ Clay Loam (] Fill Material.. .... ....If yes, type---•--------- __ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be laced on re NEW INSTALLATION: (No septic tank or see a e p verse side.) N PACKAGE TREATMENT p g pit permitted if public sewer is available within 200 feet,] ] SI=DTIC TANK Size.... �(- �.. Liquid Depth---..-.-- --------------- No., -- Capacityle�s�_aj�."TYpe. O� �" - - - ---� MateriaL +Q. ._• --No.,Compartments--.... , Distance to nearest; Well.... '--- --------- LEACHING LINE '��' .....-.. Foundation....IZ/..,-F I ] No. of Lines... .. p--line-- "'---.---..Length of each fine" - ` ; 5 e_1� � Total Length 'D' Box---1__....Type Filter Material.�.. _ ,� q\�oc-�-- Depth Filter Material.._...-/'- Distance to nearest: Well--,Y ._.f �*l.t� .--.Foundation---.-- . �1 SEEPAGE PIT p ---------------Property Line f------ ( 1 De Depth... ...._Diameter..... 10= ---------- Water -------------•-_- Rock Filled Yes k No ❑ Water Table Depth."--.....��?-�.-...-- , Rock Size..... _�.. --�----- ------- -- Distance to nearest: Well........ / f ._...A^) ---•--Foundation----.y:/) Prop. Line---47 REPAIR/ADDITION (Prev, Sanitation Permit#._...-.-.._.. .. - ... ..-- ---------- ) ? Septic Tank (Specify Requirements)._...- ._. .. --- •------------ . ...- ___ .......... __ Disposal Field (Specify Requirements).................:.. raw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County )rdinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed s ` ignature certifies the following: agent '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 o become subject to Workman's Compensation laws of California." igned---------- -- ---� -----..-------------------------------------- -- ------ -------- Owner - _ p - -------- --- ------ ---- ----------- ...... Title--- ---- ----'-r�-•!t''�f-- r9_L'�Of\ -- Of other than owner) ...._... . FOR DEPARTMENT USE ONLY ,PPLICATION ACCEPTED BY ------------------------------------------- --- - DATE .. .._: �. lVlSION OF LAND NUMBER- -- - - DDITIONAL COMMENTS-- ----------- -- -- ---------- .. - .DATE ..---.... . . ------. ----- --- ----------------------- --•------ -------------- ------------------ .------------------------ �. - •--- ----- ------------ - -- - nal Inspection b - . ..._...-. y:....... .. ... C,l --- ---- ---------------- - - - ------- ------------------- ----Date 4-S 13 24 f / - SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7176 3M r�