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i FOR OFFICE USE: r'`' FOR OFFICE USE: �N APPLICATION FOR SANITATION PERMIT r�pp p (Complete in Triplicate) Permit No._!._�/.=_lam/-�_7 --------------------------------------------------------- Date Issued___7_�"_115;--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 compliance with County Ordinance No. 549 and existing Rules and Regulations- 41 egulations: JOB ADDRESS/LOCATION. -----:---.CENSUS TRACT--------------------------------- Owner's Name AJ✓� K.A_M i. A_ f�"S- .1 . :.-. ------------- --- -- Phone" - �1 _ Address-----1")glwl6-----�;-Alj.w,�_Tom- ----- ------ ------ ..-----------Zi Contractor's Name__ s�-r. - 15. -----=------------=-------------'------ _.-License # -3�{ Phone- ��-'- �27----- c i Installation will.serve: : ResidenceE�: Apartment House E] Commercial ❑ Trailer Covrt ❑ . .. Motel ❑ .-Other-------------------- ---------- Number -- ----- Number of living units:------- ,------Number of. bedrooms:.-"-9—-_Garbage Grinder.------:-----Lot Size__.-----------------------------------" --.--._--------!.-._. t Water Supply: Public System and name-.----------=---------------------------------------- ===---- - ' -----------------------: ----------- ------- ---- Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ °Clay Loam ❑ Hardpan ❑ Adobe. Fill Material------------If yes, type------- ------------------------- {Plot plan, showing size of lot, location of system in relation to wells, buildings,.etc. must be placed on reverse side.) ' NEW INSTALLATION: - :(Noy septic tank or seepage pit permitted if public sewer is availablewithin 200 feet,) PACKAGE TREATMENT --[ j, SEPTIC TANK '[ ] Size:::-- - -------------------------------------- '#-----Liquid Depth.-------:----------------� , � � � f capacity s,T. e x-----------=--------Material =-------------' ----No. Compartments--- ----- ` ----------- .. 'Distance to nearest: Well—. ------------------------------- ---Foundation-__--- ------Prop. Line-.--------------- ' LEACHING LINE. .[,] Na. o .. .i'nes-------- -------'_--_.-_---- ,. .gth of each line.----;.-.-.--_;--.------ :-----:-,.Total Length.------------•---------_- Len tD' Box---- _Type Filter Material ---*-----Depth Filter Material--'------=----- = --- ------ - ------------ "Distance to ------=----"Distanceto nearest: Well"-------------------------Foundation------------------ -----Property Line------------------------------ SEEPAGE PIT [ ] Depth;_-- ----------Diameter----------------'----Number---'------------------------------ Rock Filled Yes ❑ No❑� P j Water Table De th---=------- ------------------------------------ - -.--- Rock Size5 Distance to nearest: Well.------- ---------- -- ---- Foundation-------------- -----------Prop. Line :------------------------ REPAIR/ADDITION (Prev, Sanitation Permit#--:-=--T_--__-:_ =--=-----.Date:-::_ -- `---- --------- ---- Septic Tank (Specify Requirements)--- - --=-------- ------=---- - -- ------------------------------------- -------- ------=-------------- -------------------- Disposal Field (Specify Requirements)------ 1 �- - ---: �?. � .--, r�'c t-�+ ---�- L---------------------------- ------- �----- - --- ---------------------- ---------------------- ----------------------------------- ------- -------------------------------------------------- - (Draw existing and required addifion on reverse side) I hereby certify that.] 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 following: i "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 I to become subject to Workman's Compensation! laws of California.". ` d Signed = ---- -------- -- --- --- --- ------------------- ----------- ---- = :Owner . _ gY ----- ------ --= Title - : -------------------- (lf other than.owner) : t E- . OR EPART T LlSf ONLY APPLICATION ACCEPTED BY--- /1'x�"- �� DATE -- -----7 - DIVISION OF LAND NUMBER= ------- ---------------- -------------- ----------- ----=--------------- DATE = = ' ; - ADDITIONALCOMMENTS-------------------- ---- ---------------------------------------------------------------------------------------------------------------------------------"-•---------- ------------------- -------------- ----------------------------------------- - ----------------------------------------- -- k ---- ----------------------- -- - -- --w - i = -------------------------------------------------- Final Inspection by�l.+�:� -� -------------- '" - [� >lfjic- - D. _._._Date--------------------------.--- ------- --------- EH 13 24 w.r4 /_ SAN JOAQUIN LOCAL HEALTH DISTRICT Fss 21677 REV. 7/7e 3M Y