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FOR OFFICE USE: FOFFICE USE:, APPLICATION FOR SANITATION PERMIT Pefimq 3 r (Complete in Triplicate) ✓f- ......... ....... .............. ......_ Date Issued.-. . p -------- ..................... .... -- This Permit Expires 1 Year From Date Issued 'X Application is hereby made to the San Joaquin Local Health District for a permit to onstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and'ezisv g Rules and Regulations: ^ - � -�-" -. _....... ........�.` TRACT_....... ._. _........._.. JOB ADDRESS/LOCATION..... -I_ ... .. ... L_`...... . ..--- -. -. . 1 ... CENSUS i 6 I �^� ' -�pC Z./✓� .. ...........................Phone..Owner's Name ... csy -S-------- Address......... - ---- Address.......' .............. Ci .....--•- --- -- -- --zip . ......... .............. Contractor's Nome_._- - License #1'_9 ---Phone Installation will serve: _ tRe`sidi:fte Q -Apartment House ❑ Commercialo Trailer Court S Motel i-] Other----.................. �� i /7 i _ Lr Number of living units:.-.___-_.. /%Number of bedrooms.. Garbage Grinder . ._....-._Lot Size_... Water Supply: Public System and-name. ------- ----- - ...------. .._...:....... _ . ----------- ------ .....-- •-----..--- -- _ Private Character of soil to a cli th of 3"feet: • Sand F1 -Silt ElClay ❑ Peat E] Sandy Loam _] Clay Loam "-r Harclpon..❑ Adobe ❑ Fill Material.. ._:......If yes, type ------------------------- -- t (Plot plan, showing-siz of-lot,,:lacation of system in relation to wells, buildings, etc. must be placed on reverse side.) _J NEW INSTALLATION: ;• (No septic tank or seepage pit permitted if public sewer is available within•200 feet,) -� - PACKAGE TREATMENT '[ ] '-SEPTIC TANK [ ] ,i.r��..�Size: y:�Z3'.....I ------------ liquid Depth.. Y..........:... Z-1Z°°gll1�x�T�n4.d Capacity</6�0' ---. Type h� (? gMoterial .--- . ........_ No. Compartments ... Z_I , }ip `/�7Y�?9 1 Distance t_o nearest: Well �(/�'£'. _-- Foundation_:_�(�_-rT---_� Prop. Line.f .. --- LEACHING LINE ` [.] No. of Lines..... ...:........ ...Length,ofeachh line___.. �C........::_-;:.:--Totall Le th _- .w`./....-....:.__...._-._..--. S ?� ! 'D' Box.:(.........Type Filter Material/�trk/' Depth Filter Material 1-_,.=1....... ..... ....... .. .......... ... /� ,„ _ - Distance to nearest:Well- ........ -. {'rid Property Line.... D�....._..- SEEPAGE PIT r ( ] i •Deloth..19 # '� Distance" Diameter.:. 3 .......Number �--- - -- Rock Filled ledY Yes No❑ Wate('Table Depth..........'....................-.........................Rock Size_ ......... to nearest:.Well ...........I.......:..........----------Foundation-.-_ .----..----.__'..Prop- Line REPAIR/ADDITION IFlev:Sanitation Permit#.... .............I........... . ...._.--------Date..... _..'"" ""^ .....,._.._....._._ ) 1 Septic Tank" Specify Requirements) .....: ..............•.......... .................................................... _.... I Disposal Field (Specify Requirements) ...........N---••- ------- .. . ............. ................... ........ ..... . A.............=-• -•------- [ .... r....r..._.r �_-.._..:.,. ,. .:...........................•-_......�Tom -r: r --- .........:......... .........----------------- ------ .. ...........,....... ------- -- ... - - j (Draw existing and required addition'on reverse side) I 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 _ ..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 `A to become subject t man's ensatiort laws of California." I Signed . _ .r ......._.. -:.........-- ... .._Owner l BY= Title . --•---....._ - ---------•---------•--------- .--..... -- ..... i E [If other than owner] F05 DEPARTMENT'USE ONLY / 1 APPLICATION ACCEPTED BY.- DATE�� •. DIVISIONOF LAND NUMBER.. . . ......:.............: ......................-..........-................... .................DATE......................... - ----ADDITIONAL COMMENTS............. . .................... ........................... ......I................ ............................................... ...... I. , ! [ ................... -_.... ............................. ...•------ ..-. _............_.._.................. . ---..._.......... .......... ---'------ ... . ------... ` -•---- -- ..00fie- ;A .:... 1 :: �A Final Inspection by.. ..... �. 'v ---- .y ' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV.7i76 3M _-:r