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r r FOR OFFICE USE: ' FOR OFFICE USE: 1 APPLICATION FOR SANITATION PERMIT �G -------------- • Permit No._�7---- (Complete in Triplicate) ------------------------------------------------------ `�• =� .s` o--!3` 7 4-».w..-• Date Issued___'" -� ------------------------------_--------------------------- ,.This Perm It 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: .. _ ... x a m JOB ADDRESS LO TION_ - - ._ -------- ./ 2iJ=• .e----------- _.. ;-...CENSUS-.TRACT-----------------p---------�--- Owner's Name c -�; ------------=--------- - -=--------------------:-.-- -- - Phone_ � �_ `_- - q' i Address--- - -------- - --- Ci - Zi . tY p------- ---- - Contractor's Name-- i&A - -----=-------- License #-o171 Phone--Vems- l ---- --- Installation-will server Residence [r Apartment blouse❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------- 7 Number of living units:_____ __N tuber of bedrooms---�___Ga age Grinder__________-Lot Size___. �:_��---------------- ---- ------------------ i Water Supply: Public System'and nortne - ------------ ---- - _ �-(J -- ------.Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Si ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Wardpan ❑ Adobe Fill Material--------- __If yes, type------------------ --- -(Plo(PI 't t plan, showing-size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: ' (No"'s'eptic tank' or seepage :pit permitted if public,sewer is available within 200 feet,) ; t r. PACKAGE TREATMENT [ p 5EPIC TANK (.] Size---- ------------ -!-a `.______________-'---_-�-----Liquid Depth._.--- ---------------___-_,I # ' V' 1 Gapaaty-- ----------- Type al f __r:No. Compartments `= F1 Distance'to nearest: Well --'- --Len -th of ea -- lin Foundation__ ______ ________Prop. Line__ s o4 LEACHING LINE, [;]_ No. of.Lines.- g e.-- ---------------------------Total; Length----------------------------------------- I -___...___;.._.Type.F--i•lt-e-r Material --------.. __ Depth .F,ilter Material- --------------------------------------- --- ----! __ Distaneto nearest: Well........--------------------Foundation-----------------_------------Property Line----------------------------------- SEEPAGE -------------------- --SEEPAGE PIT -- ------Diameter- --------------Number___ ._____:----- - Rock Filled •Yes ❑ No ❑ Wate Table De th--- -----= - Rock Size ----- p ,- Foundation------------------------ -Prop. Line =---------- 'Dista`6c6:to nearest:Well_- I.;= ------. I % ( _ � ---- - -----"=------=- --- ) � REPAIR ADDITION Prev:Sanitation Permit#--i------------- _________________. .Date. Septic Tank (Specify Requirements)---------- -- = -- ------------ ---- -------------------- - ------------ -- ------� -- --------- ----F----------- Disposal -------- +Disposal Field (Sp ify,Requirements)------ = '� � "`"` 'fir 'J�--- ----- :--- r s C -- --- - _ ------------------------------------------------------------ ' t ------ - _. _ - ---- -------------- -------- --- (Draw existing;dnd_required addition on reverse side) I hereby certify that.I 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 cortifies the following: 1 t "I certify that in the performance of'the work for which this permit is issued, t shall not employ any person in such manner as to becom bile to kma Compensation,laws of California." ° Signed : ---- ---------------------- ------- --------Owner i By-i - -----------------------Title. = - -- --• Of ther than owne / 17 f0k. DEPARTMENT USE ONLY y" APPLICATION ACCEPTED BY-.----: ---- - r ; ---=------'----------------------------------- ----- ------------------------DATE -------- DIVISION OF LAND NUMBER 1 •--- ------- - --------;_DATE------ --------- ------------------------------ ADDITIONAL COMMENTS- = J-------- ---- -- ---------- ----- --- ----------------- - ° _ -------------------- --------- - --------------------------------- ---- ------ ----------- ---------- ----- i - ---- ----- - - - -------------------=------------- ------ --------------------------------.--- -_------------------------- � ----------------------------------------------------------------------------------------- ---- --------- Final Inspection by = L!� _.r�;AN .._ _ =- -------- ---------------- ------. --Date. /'rs f`� 7------------_ -f EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT Fas sib��REV. 7/�6 snn