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FOR OFFICE FOR OFFICE USE: t APPLICATION FOR SANITATION PERMIT -------------------------------- - - IComplete in Triplicate) Permit No.. .__'_�1 �� ? ------------------------------------------ Date Issued__.-------------- Th'is Permit Expires 1 Year From Date Issued r/1 Application is hereby made to the San Joa uin 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 1-7a, ----- ----------- '------------------- -- CENSUS [RACT-------------------------- Owner's Name---- ------ .. - -------Phone--- - - - Address-.---- Q ^. _. Iyfi� = City.. Zip- - .. . Contractor's Name --- .... . . :License #_ :j4 r—P-hone--- ��Q �� Installation will serve: f ResidenceApartment House [] Commercial ❑ Trailer Court Q 7 Motel ' Other= `--- - ------------------- 6-1 _ Number of living units:-------- ------Number of bedrooms -3___.G.arbq'ge Grinder____._--._--Lot Size___._--_,-,.,_ • � is S Water Supply: Public System and name ---------------------------------------------- '------- ---- ---- ---------------Private ❑ Character of soil to a depth of Tfeet: Sand [ Silt Ll Clay❑ Peat ❑ I—Sancly Loam ❑ Clay Loam ❑ ' Hardpan❑ Adobe. [ Fill Material------------lf yes, typei----------------------- / (Plot plan, showing size of lot, location of system in relation to wells, buildings,.etc. must be placed on reverse side.) NEW INSTALLATION: ' '(No"septic tank"'or`seepage'pif permitted if public sewer is available within 240 feet,) PACKAGE TREATMENT [ ]' SEPTIC TANK. ['.j" -` ie .___ ---------------------------- ----------------Liquid Depth.-- ---- - € ; t, r Capacity --------------jype-, ..Material-------------------- j-1 1o. Compartments---- ------------ ----- Distance to.nearest: Well- --------............ Fouridat.ion____----------------------Prop, Line---.------------------------- LEACHING LINE [ ] No. of Lines-.___-,._'_ ____ Length_____________ • of each line.._;_.__. . __ - I__.Total Len th.__.__ Type ------_ - .Depth Filter Material i - � -- -------- --- - 'D' Box ;-_T a Filter Material _ _ .. ice.'—t_ _ -� '—�.--�--•-� I p� .F=_ - ,4____ __ _____________ _____r-_____ _ ' = Distance.to nearest. Wel! f=oundation - � i ---, . . .. .... --;----rM.Pr Line------------- : SEEPAGE PIT [ ] Depth.-_ -_ --Diameter- .------`_._.N-umber--------------------- -------------- ` I Property Filled Yes ❑ No' Tp Water Table Depth----------------- ------=-------- `---- '__R,ock Size+-' = -------------- Distance to nearest: Well------------------------------ -Foundation - -'- ---- - Prop. Line---------------------------- REPAIR (Prev. anitation'Permit#-- -==--`-- -----=----------------- ------>--__ Date-�----:----' _-�--=`-------- -------- [ .} ' .T Septic Tank(Specif uirements)------------- --------- - = i t ---- - 1e d (Specify Requirements[ �. �CGZ - -------------- = - - ----- - -------�� K--- _ ' --- tet E I ---- ------ r --------------- _ n, . -------- raw zistiri.--aqd re wired addi --- - - --- -- ---.- tion � � � - -�� + � 7 -- (D:. g in q 'on reverse si e[-` . I hereby certify tha6 e prepare"is application and tha-nhe w`ark will'be done.4;)accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the: San Joaquin Local HealtFj 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,--11411�ro+ employ any person in suih manner as to become subject.to Workman's, Compensation laws_of .California." Signed------------ - = Owner BY _ = - ----- _ itle: --------- ------------------------------ [If er than' vier) 1:N I - ' • '^�: b F EPART`Mi SE ONLY APPLICATION ACCEPTED. BY- -... = DATE. Z �� _ DIVISION OF LAND NUMBER. ------ ------------------------------ + DATE._..-- -- -.--- ---- ADDITIONAL COMMENTS-- --- _ ]. _''- it_ ... -----�------ - - --- ------------------------------- i -----------------------_--------- --ClQ _Ife o .U1 k--------------------'----------� �} ------- --------------------------- --' '- - Final Inspection - -- ' ---------- f - ---Date. /� j?$ EH 13 24 ,. - SAN JOAQUIN LOCAL HEALTH DISTRICT I F&5 21677 REV. 7176 3M