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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ --------- Permit No. /7 (Complete in Triplicate) 7 - -------- --------------- 11 fssued�-3-�_f 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: JOB ADDRESS/LOCATION_ CJYSC G f�Y a,Gr ---- - ---------CENSUS TRACT-------------- ---------------- Owner's Name.-.,,'--- .� -----( 'v�`� -'' --Phone---67 Address °` s- `?--c� ---------------- ----- City - e_ .s`. Zip q -'may'.. Contractor's Name--- r` - ;'�k�- G_i -n?.� `----•------------------------------ License #_z7_ .7 `�� Phone__g yz1 „�.-b4 k-- Installation will serve: �esidence Apartment House,[]-,Commercial ❑ Trailer Court ❑ Motel ❑ -Other--- Number Other-_Number of living units:.------ - ------Number of bedrooms_._,.---Garbage-Grinder---------=_.Lot.Size--.------------------------------------------------------- Water Supply: Public System and name------�_-------. _ t Private - -----<. ----- --------------Privatelk of soil to a depth of 3 feet: Sand ❑ Silt Ll .Clay ❑ Pat ❑ Sandy Loam [�r Clay Loam ❑ Hardpan ❑ Adobe❑ Fill .Material-.._.-_._._If yes, type-----------------------_______ (Plot plan, showing size of lot, location of system in relc,fion toywells, buildings, etc. must be placed on reverse side.) +k NEW INSTALLATION: (No septic tank or seepage pit permittee if public sewer is available within.200 feet,) 00 PACKAGE TREATMENT [ ] SEPTIC TANK p�] Size--.- - �_V�_______________":____.___________- iquid Depth -------------------------- Ca acit �.Z,C7C� T e '------- ---------Material-- C`c° ' No. Compartm"ents- --�---------------------------.J J Distance to nearest: Well��-VOtPSN'------- ' Foundation_-_._�O_ _�-,_t__Prop. 'Line---------------------------- LEACHING --------_ --_LEACHING LINE [�.]' No. of Lines-------__ -----------------Length of_each .line. ?_C7___ ___.___.Total Length.. _ ...._ _-\________________ _ amu -., � rr D' Box--A-------Type Filter Material---" �__.__. epthiFilter Material-_-- -- '`- -- -------------------------------------------- Distance to nearest: Well------ "_Foundation_____ --. ------------- Property Line F Depth_3`_.�__.__Diameter-.---�'A_ _-_Number_____ay__-.___-_ _______-_ Rock Filled .Yes�7c' No • i-P . . WaterTable Depth--------- ---------------------------------------------Rock Size--- -------------------------------------------- Distance to nearest: Well....V OTO '- -V.7--------------Fou ndation--lOG- .--.Prop. Line---------------------------. REPAIR/ADDITION (Prev. Sanitation Permit#--------------- ----------------------Date-----------------------------------------------) Septic Tank (Specify Requirements)----------- -------_------------- ' Disposal Field (Specify Requirements)---=-------------------- -------------------- ------------------------------------------------------------------- -------------------------- ------------------------------------------------------------------------------ ---------------=---------------------------------------------------------------------------=--------------- -- ------ - ----------- ' (Draw existing and 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, II shall not employ any person in such manner as to become subject to n/rykman's Compensation laws of California." Signed u '�-- ----Owner BY------------------ -------------------------------- ----------------------------- -:---------------------Title----------------------------- ------------------------------------------ (1f other than 4owrier) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- -f ---------- ------------ --------------------- ----------------DATE.----- �r '.79------------- DIVISIONOF LAND NUMBER.----------- -- -------------------------------------- ----------------.DATE.------------ ----- ---------------------------- ADDITIONALCOMMENTS---------------------------------------------------- --------------------------------------------------------------------------------------- - ------------------- -------------- --------------------------------- ----------- --------- ----------------------------------------------------------------------------------------- --------- --------------------------- FinalInspection by:---- ---- --11 -- -- -- ------------------------- --------------------------------------------- Date Z - -------- ----- EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/7e 3M - � f