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FOR OFFICE USE: - FOR OFFICE USE: 'PLICATION FOR SANITATION PERMIT � (Complete in Triplicate) Permit No._�._.._ .._.._-_ ._ . .-------.................._..___._--------- _.-. This Permit Expires 1 Year From Date Issued Date Issued. _ -. ADplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T s application is made in compliance with County Ordinance No. 549 and existing Rules-and-Regulations: - JOB ADDRESS/LOCATION -- -------- - -- --- - --.CENSUS TRACT._---- - - - t vner's Name...- R- .f. Q------ _AW;_• . _...._.Phone_ 3 - - - - - - ------ -Fk-( =�- C 1R9dress ��'a'D. �S�-'-� �e^�Q� .-��--------------------- - - --City.. - r -'h��o�- - zip-. 4`- `�S Q Contractor's Name__95.et...7ZI.c1S---------------- ----------- ------- --- ---------...-..license #----------------------------Phone-.-----_ -------------- ! stallation will serve: Residence❑ Apartment Hou RCorpmerccip�I E] Trailer Court E]i Motel ❑ Other_ -- -11------A. -4------ "'jmber of living units:----------------Number of bedrooms------------_Garbage Grinder------------Lot Size---A41144.t --.-----._.------_ '.,ater Supply: Public System and name _____.----------- . ---_ ----.----Private A3 Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam❑ Clay Loam al Hordpan.1KP Adobe❑ Fill Material------------If yes,type_____---___.._____..._- of 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 feet,) 7 i �aCKAGE TREATMENT [ j SEPTIC TANK P0Size-.5 .l0 YS__-_- __._:.__._._.__-___._Liquid Depth.__._y._-...--- .._.�/ Capacity_jX49e,-------Type}±A�04> -----Material._4-10----------------No. Compartments.---;c------ ------_____ Distance to nearest: Well------ ---- -----_----.-------.------------Foundation_---------__--------..Prop. Line--------_----------------- � IL'EACHING LINE 91 No. of Lines--------L______--. ----Length of each line.._Ale- _. ---------- ..Total Length._'Ya_'______ H 'D' Box. __Type Filter Material-_�t...i.__Depth Filter Material__/-Q.._._...._.__..__.__.__._...._______________ Distancatongarest: WelL._L _�_ ________Foundation.__1a':=._.---__.--.Propertyline.sj.�_.-_._._..___- _ 1. - --- P IT #Yj Depth: __.Diameter...s. ._-.>��.__..Number-__. .-______� Tlg �JG�' Rock Filled Yes No. Water Table Depth----r--;2---0-------------------------------Reck Size-.J.-,f---------------------------- � Distance to nearest: Well---ISR._----- _Foundation-----l0__. ---- ----Prop. Line._4�_.-.___..__-.._ REPAIR/ADDITION (Prev. Sanitation Permit#-.---_--------------------------------- ---------Date_____ ------------------------------------) s `aptic Tank (Specify Requirements)------------ ---------------------------------------'--------- Disposal Field(Specify Requirements)---------------- ----------------------------------------------- ------- --- - -------------------------------------------'---------------.._._._ (Draw existing and required addition on reverse side) 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, I shall not employ any person in such manner as becom{�,�+�biecto Wor(�]�gan s C pensation laws of California." Signed---1✓ -`rte") '-- -4•-- -- --------------------------Owner 3y------------- --------------------------------------------------------------------------...._ _.Title .--------------------._------------------------ (If other than owner) FOR DEPARTMENT USE ONLY YPPLICATION ACCEPTED BY -- ...... _ DATE %L '$-7 - --------- ---- -- ---- -------------------------- DIVISIONOF LAND NUMBER.--------- --- ------------------------------- --DATE.----------------------- -------------- ----- ADDITIONALCOMMENTS--------- -----------------------------------=------------------------------------------------------------------------------- ------- ------ ---------------------------...------------- --------- ---- -------------- ----"-------------------------- LFinal Inspection by:-.--:✓`'i _-------�` i------------------------------- ----------------- --------------------.Date--------------- H 13 44 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 216" REV.7/76 3M