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FOR OFFICE USE: . FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------�:3-°- Permit o----------------------- ,573 (Complete in Triplicate) N ____________ ______ - -------------------------------------------------- Da /x'17 te Issued._.' •-- _ -,, --LL__ ....,....T{his 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 49 and exis ing Rules and Regulations: ' JOB ADDRESS/LOCATION ---. ---------_-- --`� � -------- - CENSUS TRACT p' ?.. 1. . Phone 'V77 Ql� Owner's Name-----------------i:/ --- -- --- -- ----- - --- - - - ----- --- -- -------- --. -- w. __ „ ----------- ----- : - z Address - ---------- -- -' = ity 4 s A. •�.- C Zip / . : --- Lice ... Phone Q ' Contractor's Name._N'-�- - -- -----Gt'L/t �,=.- --- sem' - License # S' Installation:will serve: f! Residence Apartment ldouse.[� Commercial ❑ Trailer C } u t ❑ ; Court € Motel Other- - ---------------- `--- --_----------_--- .. . 1. Number of living units: . obm_Garbage-Grinder--%-__--_--_Lot Size-- PrivateWater Supply: Public System an&name---------------_----- ----------------------- -------- - ----- _,--:----- - -----' -- - -------------- Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ . Peat❑ ISandy Loam ❑ _Clay Loam ❑ i Nprd'pan AdobeA Fill Material:. - _ 4 If yes typ e ---- (Plot plan,sho g size`of lot, location of system in relation to:wells, buildings,:etc. must be placed•on reverse side.) f NEW INSTALLATION: =(No.-septic tank _or.seepage pit_permitted�if public sewerxis.available..witbin.200 feetA _ — ` 3 ' S6TIC TANK ['] SizeI _-- Liquid Depth. ------- I PACKAGE.TREATMENT [{] z . - -; :: 91 ' .:Capacity--'._-� =Type-----:__-- y--Material _ ` --- No: Compartments--`_-- r ? i Dii - ; stance-to-nearest: Well' ________ _______Foundation __.--_. _____ Prop. .Line LEACHING LINE [ ] No,of Li a�= -- V ---A_Length .ofleach line� "F- _ :. .______ --,. a=-__._ Total Length � Material =- ---De Depth Filter Material -=--------- ---------------------- b , Distance to nearest:-V�Ti eILi----- --' _- -.... Y . ' Box...... _'___T e. filter Mater O • � � � Foun -'-----------------,Property Line --------- ----- --------' dation _ � i SEEPAGE PIT [ ] De th•- Diam2 r__ � _ Numbers__ ___ Rock Filled ' Yes.❑ No ❑Z r t _ Water Table ept � ----,---- - - Rock Size; y : Well ---- Foundation- -- • Prop. Line- , A. *� - REPAIR/ADDITION (Prev,Sanitation Per ` -- ---- ----- --- ate 3 1 _.D ! s 1. Septic Tank (Specify Requirements) ___. n ----------------------------------------------------- -- ------ ------ -------- -- ------------- D ----------------------------------- - Disiposal Fie pecify Requ' ements) r - ' ? ti . - . . ------- .-----,.-------- ------ -. ------ - �l i� f ��-�� --�C--� -- - --------J-------- - - = " - [" (brave exist3n-g,70 e_quired addition on reverse side] `. I i that I have prepare this a licdiom and that the work--will be done in accordance with San `Joaquin County I hereby certify p p pp ? Ordinances,. State Laws, and Rules and ReulaFions of the San Joaquin Local`Health District. Home owner or licensed agents signature certifies the following: .�," L--�*" "I certify that in the "perform ce of the work for w ich,this rmit is issued, l shallnot employ any person in such manner as to become s Lett fio , s Compensation' I sof+ C fornici. t Signed- = -- = + s . :_. O By - =Title ----------------------------------------- --------- --------------- -----------=- ' : ... ., (If other"than owner] . `�.�. • •� ""FOR,DEPARTMENT USE'NLY, APPLICATION ACCEPTED BY{--__""____ -- r' • '� ATE `a._.�`� .- ---- ----------D DIVISION OF LAND NUMBER- -------:; ------- ------------------ - -------- --- '-------------------------------------- DATE _ -_ ] ADDITIONAL COMMENTS_°-----------'-'------------- -------------.-------- - - rw-=---------- - -------- -- -- ------- ------------------------------------------- ---------- -----' I __ _ - ---- - _ ---------------- -- =_' __________ ___________ --------------- ______-_ --_----.______-----_------._ _____._________ _ __ -. i..__ .-- _. : - ---------------------------------------'--- -------------------- ------ ----------------------- - - ---- ---- Final Inspection by:- -: - - Date.___-- ._._ _--. ---t ----'----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 2167 _!