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FOR OFFICE USE: 4 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT = ---- ------- --- ----------- --- ---------------- 1 ,I r Permit No� (Cam�leteii�`4riplicate] L`b � � IS S Date Issu,6d_7-.17-_._.__ ----------------- --------------------------------------- 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: ADDRESS/LOCATION------------ r.:: ` '+ - -�?1 -- -- a - --------� -------------- M - .CENSUS .TRACT --------------- JOB Owner's Name-=----- ---- rZ ------- --------------------------------------------------- - - -- Phone__._ �C}2 c, Address-----._Zll-21.. ARS .t-'�.- City -FR a ------------ c dip Contractor's Name C -6i1 = Y License .# 3`�/fff-f- $ Phone 6��' .. ----- :---- ---- Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other -----------] ------------ ------ a ! Nuimber-of living units:--. �� _.____'______Num bar of bedrooms____ ' _Garbage Grinder..._....'-Lot Size-------�_��2 �_. .__�. _ -. ` t Water Supply: Public System and name = ---=---- -----=------------- ----- ---- - - ------ ---------------------------------Grivate Character of soil to a depth of 3 feet: Sand 0 ;Silt E] Clay ❑ Peat ❑i Sandy Loam ❑ -Clay Loam E]Hardpan E] Adobe❑ Fill Material............Iftyes, type_________ ______ __________ (Plot plan, showing size of lot, location of system in relation to wells, building/0etc. must be placed on reverse side.) NEW INSTALLATION: (No-septic to"n'k'or seepage ;pit pe mitted if public'sewerLis available within 200 feet,) - � -� � _ PACKAGE TREATMENT [ ] -rSEPTIC TANK [`] Size- -_-.��.: _" � ---- ------------ ')b _ Liquid Lf t�Z �' r. Li uid Depth--------------------------- f Capacity:,---1 -�--'---Type- ---Material-- i_No. Compartments !� \ ` j. Distanceao near.est: .Well.' Fovnclafiion-- �,V--,_.._. ,.prop. Line---------------r `LEACHING LINE' [ ,] No, of Lines ,_. ,�---------- , ,_Length of.each lies, -- -�� ----- Total Length.---------------------------------------, $ 'D' Box---1_------Type Filter Material--- --:``2-----Depth Filter Md#cal ,y----------------------------------- ------- v „ t Distance to nearest: Well_;_______ I -'-----:-----Foundation --,----d----- - = Property Line-- -------------------------------- SEEPAGE 5 SEEPAGE PIT Water Table-De th._-;__-- --------------------- ------- Number____________________________ Filled Yes;❑ No De th-----------------Diameter---_--- -- ----.. ..:. `U p ----------------------------- Roc iz ------ ------- ------------- . k 'S a-__ _ � � �. 1 iDistance to nearest: Well-'------------ ------------------- -------Foundation-- .----- ,-----E_ Prop L r-------I-----------------. REPAIR/ADDITION (Prev. Sanitation Permit#-- ----------------------------------------------Date------------._---:----------- -, �- - ) 1 Septic Tank (Specify Requirements)------------- -------- --------------------------- ------- i - Disposal Field(Specify Requirements)-- :- ----------------------- -------- ----------- - - f -------- ----------------- -----`-------------------- r ------------------------------------------------------------------------------------------------- --------------- ---------= ----- s (Draw existing and required addition-on reverse side[ 3 i I hereby certify that I have prepared :this application and that the work will be done in accordan�a with[San Joaquin 77 County Ordinances, State Laws; and Rules and Regulations of:the Sari Joaquin Local Health District. Home owner or licensed agents signature certifies the Following: ' "I certifythat in 'the i p employ Y P �n perfoiriiance oF�the work for which this erniit•is issued 1 shall �nofi em to ori person in such manner as to become subject to.Workman's ..Co ensation laws of California." t Signed._„-- - ---- - '. T ....--------._ -Owner By------------------------------------------------ --- - --- ----------.--------------------=------ -- Title--------------------------- ------=-------------------------- ------------ (If other t owner) t 1 t FgiR DEIYARTMEV USE ONLY' APPLICATION ACCEPTED BY E"^- ---- _-.:---- _-DATE - - _ -- -- -------- DIVISION ---- ._DIVISION OF LAND NUMBER------ ------ ---- -- -- --------------------------------- -----------------DAT��v --------- ADDITIONAL - . ! ADDITIONAL COMMENTS-----=------ ------ ----------------- ------------------ --------------------------------=------------ -----==------------------------- --- -----------------------"-_------- ---- -=------------- -------------------------------------••-------------------- =---- ----- -- --------- -------- - . .. 4 ______________________________________ fr __ ________________________________________________________..___________._________.____.___._.____________________________________._- ' 1 i FinalInspection by:......-_ -------------------------------------------------------------------------------------Date---------------------------------------�r�te� EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV,W6 3M -.�. ti-