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t - FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No.-7/7- ---------------------------------------------- --------- 71111\ ,,,, _...,.� :Date Issued../:_.`Z�---?7 c-This Permit Expires ] 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 Or inance o. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT ON. �Q --- -- ---�.--. i -- - CENSUS ^ ; Owner's Name Name-------- ----- hone --------- . Address - _.. e_ O , ----- - _ - --city - i .-.0 tY - -- ----; Zip = Contractor's Name_ _ -` - -` - License #.v�?L.s�_ .E'T Phone' ti ! ! Installation,will serve: Residence artment House.[) Commercial 0 Trailer Court ❑ Number of living units:__ _' # Motel ❑ Other ______ __ __-----_---------------- Number __ - - - -- -- { �. :_Number.of.be'drooms-�.-_--Garbage Grinder........ Size__- ` __ Water Supply: Public System and,name----------------- -------------- -------- --------------- ' } t ------------------------------------------------ ----------------- rivate NIP P W Character of soil to a depth of 3 feet: ;( Sand ❑ Silt❑ Clay ❑ ' Peat ❑" Sandy Loam ❑ Clay Loam�' •Hardpan ❑' Adobe Fill Material..____g.---If yes, type... __--- ' (Plot plan, showing size of lot, location of system in relation to,v✓•ells, buildings, etc..must be placed on reverse'side.) NEW INSTALLATION: (No-septic tank or seepage pit perm.itted-if' 'Public sewer is available within 2D0 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size-- - `C ---------------------------- Liquid r- Depth..-- -,------- pateria -No. Compartments_._- t acit - _ JOL sDtance't�nst: Well. -- --- - 4 �Foundation _ Prop. Line--------------- ! LEACHING LINE � .S""� [1' No. of Lines_.___..D _..Len `th of each lins._d 'ryryS= 9 d.- Tata! Length ---------------------- 'D' Box-----/___-Type Filter Material,S_'_MaC�'- eptMaterial--- '---/9 Filter Mial __/9---_.__--- __ r I .. ;, a = Distance,to nearest: Well- /420-r - __---Foundation_15� '_ Pro perty Line SEEPAGE PIT Depth_/6- _-f„_.Diameter �- � �� , Rock Filled Yes R;---No ❑ i Water Table e' th---------- -0716_ Y ... - ---Rock :Size, ,, PF . i --------------------- i Dis#ante fo nearest: Well___ �----------------------------Foundation__�� _ .Prop. dine_-.__ i ' 6 ---- REPAIR/ADDITION (Prev. Sanitation Permit#_ -_: -_.Date___ ----- -- ------ == t - ---- Septic Tank (Specify Requirements)-__----_--_i- s = :_: --- ------------ -- Disposal Field (Specify Requirements)._.__..--------------------- 4. . _ -------=------- ---------- ---------------------------- -- --------------- --------------------------------------- --------------------------- --- (Draw exist3ng 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 andrRegulallons of -,San San.Joaquin_Local Health District. Home owner or licensed agents signature certifies the following: a "I certify that in the performance of the work for which this permit is issued, 11 shall not employ any person in such manner as to ecorn . - ec to :�an' Com . CalifPensation, lawoornia.',' Signed - . Own er ,t BY------------------------------------------------- = fro ---Title---------- i --------------------------------- Of other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ - -------- -------- ------------ -- DATE. 7:- :. ' ------ ------ r f ISION OF LAND NUMBER. ---- -------------DATE-------------- -- _ ITEONAL COMMENTS..-------._---------- ---------------------------------- . ---------------------------.----------------------------- ------------ -------------------------------- ------------------------ x --------------------------------------------------------------------------------- ----------------=--------------------- -- - aldnspection _-- - - -------------- P EH 13 2e, - ----------------=------------- -------Date.- -------------------------------- Fin ' -- ------- ------t--- Fin �AJOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3m