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„�. FOR�OfFIE�� USE: i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT o Permit No- ------- 7 �-------s�-- • -f i ------------•...... ................ .....I (Complete in Triplicate) I ---- Date Issued�dAY._-•...........•........... .. ........... This Permit Expires 1 Year From Date Issued he ta`the San`Jaaquin=LocaI Healtl'lbistrict for a-permit to construct and install the work herein described. Application is hereby mad This application is made in compliance with County Ordi nce No. 4'9Larid existing Rules and Regulations: JOB ADDRESS/LOCATION _p . ` ... ------- -...CENSUS TRACT_....... - ...... . . ....... Phone-. . . ................... Owner's Name.... _ w”. :..._....Ph - .. City---------- -- ---- Zip /f�(Q :. (f l"( Address------ .. . _ - - ---- -.-- ---- ------ --..... -----�- - -- ` -- ...License # VI/71 ....Phone.. --- Contractor's Name.- ..-. ' Installation will serve: Residence E] Apartment House ❑ Commercial C] Trailer Court ❑ I Motel ❑ Other. --- - ---- ------ '� w Number of living units:...... ........Number of bedrooms.-..A. ...Garbage Grinder_.-.---- -LotSize ------ - .... 4 .... .. i , t ; - privet *.. .................. Water Supply: Public System and name.............._. X, a_ Character of soil to a depth of 3 feet: Sand.❑ Silt El Clay F1 Feat.[] Sandy Loam [] Clay Loam [I 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.) — I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer within 20fl feet,) is available PACKAGE TREATMENT ( } SEPTIC TANK ( � Size.............`-------;----. ------------• ... --- Liquid Depth.._.:---...-...._.. -No. Compartments_---- ......- �� ' Capacity--....;..._._-------Type------ - ------ ----Mate.ria(`_-----•'��----•--..._.- k :i E Distance to nearest: Well.`. 'Foundation..--- Prop. Line S �.-- LEACHING LINE ['l No. of Lines ------------------•_-------.Length of each line ------------- Tata! length -- --------...........__ ....... ` 'D' Box..... .....Type Filter Material... ................Depth Filter Material.....-...............-------------------- ------------------ E Property.Pro ert Line ---•-- -•----- - ..._..r, Distance to nearest: Well-____________________:..__...Foundation.-.------------------- � ------- Rock Filled Yes E]-.-,No SEEPAGE PIT { } Depth.-.... ...Diameter---------------_--Number-_--_---------;----- F __Rock Size.- -------=--- ------ -- S Water Table Depth------_------------- ------- --- --...._ E ..Prop. Line -- Distance to nearest: Well-------------------- Foundation-•-------------...... C I REPAIR/ADDITION (Prev. Sanitation Permit#...__..- y..---- Date------------- j - - ---------------------- Septic Tank (Specify Requirements)....._.... .. - Disposal Field (Specify Requirements)..-_--- ---- ---• f"` ..^.=• - --.�` ---------------------- ----------- ------- ------ - ----- --- -- ------ X------------------------- --- is .... -- - --- -------�..:....:.....:---: (Draw existinguand required addition on reverse side] accordance with San Joaquin County I hereby certify that I have prepared this application and that the work will be done in Ordinances, State Laws, and Rules ancl-.kegulations 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.f r which this permit is-issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California. - ..-_Owner +�" Signed_. f.. BY �°.._.. --- ---- - 1.... Title.._.._.__... (If other than owne FOR DEPARTMENT USE ONLY r ---------------- ----- --------- ---- DATE --- ..... APPLICATION ACCEPTED BY; DATE.... -------------- -.-- DIVISION OF LAND NUMB ...------- �--. - - ----------- . ADDITIONAL COMMENTS.- ------- ..---...--------------------- ------------------------.......... ... ---- ----------- .---.--------------- -- •.... ........... ----- --- -- -- •-------------- �- t -- Final lnspetnon b . �" �'- --- .... ...-............- - - --------- . - - y��-- ��-��---: - - FL.521677 REV. 7l76 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT