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FOR OFFICE USE: ✓ FOR OFFICE USE:- 1 *;I PLICATION FOR SANITATION PERMIT ------------------------------ ------------------- (Complete in Triplicate) Permit No. __/-/_-______ -------------------------------------------------------- Date Issued_-/--3-7_7/q ________________ This Permit Expires I Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and,inst t ro Fp—)Tr-,bed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regul JOB ADDRESS/LOCATION...... -------r/(-___-__._.__.____________- _ __.CENSUS TRACT--------------------- Owner's;lame .(al' .G/P .� 5 Phone�3---al'E��{ ----------- Address - j: / 5'0f�. S• Cam/ City.. �d- ZiP '536 = Contractor's Name------Tey f7--._ l_Gy12r -Sdr�-----------------------------------License .#_oz9�-_3_�----Phone_ Installation will serve: I Residence ❑ Apartment House❑ Commercial. - Trailer Court ❑ Motel ❑ - Other---------------------------------------------- Number ------- ------Number of living units-----------------Number of bedrooms------------Garbage Grinder----------_-Lot Size------- - ___-- Water Supply:.Public System and name---------------- ------------------------ ------------------------------------------- ------Private ' Character of soil to a depth of 3 feet: Sand X Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ 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.) ' NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feat,) j PACKAGE TREATMENT ( ] SEPTIC TANK ]' Size------------------------------------------------------_-----Liquid Depth--------------- ------ _-- Capacity__P�a-------Typekegi'gf----- Compartments--------Z�------------------- ---- Distance to nearest: WellY/Q.- fQa ------------------Found ion.-----2��______-_----Prop. Lin ------------------------------ j LEACHING LINE f�)" No. of Lines-----------/- _ ______________Length of each line. _-_ [._.___._________;_.Total Length ---- _ ------------------------- 'D' Box_A's...Type Filter Material__)40 ------Depth Filter Material------- ?_._-___._____ - -----------------------____ �.• Distance to nearest:Well___ Sr 4De_�_____Foundation-____ .��_�________________Property Line.____-_ 5________.________... p Rock Filler) Yes �❑ SEEPAGE PIT [ ] Depth ❑ No' WaterTable Depth---------------------------------------------------------Rock Size-------------- --------------------------------- Distance to nearest: Well-------------------------------------------------------------Foundation-------------------------.Prop. Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------•-----.-•------------------.Date----------------------------------------------) I Septic Tank (Specify Requirements)----- :_._ , - i Disposal Field (Specify Requirements)---------------- --- - -• - ----- ---- -------------------------------- .........-•------------------------------------------------------- ----- ----- - •- '.� --------- - '- (Drow existing'-and required addition on reverse side) I hereby certify that 1 have prepared this application--and that-0e -work-will-be--done in accordance with San Joaquin County Ordinances,' State Laws, and Rules and Regulations of they San Jodquin Local Health District, Home owner or licensed agents signature certifies the fallowing: _ "I certify that in the performance of the work for'which this permlit`is issued,T shrill not employ any person in such manner as to become pubject to Workman's Compensation laws of California." Signed = j�__ .:_:� t .�.- . - ----- --------------------------Owner 000, By-A.4•�1 �� '.-_CYC Titlei/u (If other than owner) 9t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------ - -- -- - --- -------------------------------------------------- ----------DATE.----- '7- -- r - -------:--- DIVISION OF LAND NUMBER.-------- ------DATE-------------------- ADDITIONAL COMMENTS----------- ---------- -=-- --------------•------- -------------------------- ------------------------ ------=-------- ----------------------_------------------------------------------------- =- _- ____ _ -------- -------------------------------- ------ ----------------------------------------------------------------------------------•--•------- ----------- -------------------------------------- --------- ------------------- _________________________________________________________ ___ __ -.___��__'_______________________-_________..____. _ ___. ._--__ ___-___ __ S _- ____ __ _ ___ ____ -_ Final Inspection b ---- r---- •- ------------ --------------------------------------------Date---ff c� -------- --- F&S 21677 REV.7/7G 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT I