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i FOR OFFICE USE: s� FOR OFFICE USE: ......................................................... APPLICATION FOR.SANITATION PERMITPermit No./.�. (Complete in Triplicate) r• k ....... y Date Issued-S.-_�:�`- --=. .................................................... .... This Permit Expires 1 Year From Date Issued �. Application is hereby made to.the Sanlioaquin Local Health District for a permit to construct and install the work herein described. .. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION..._6- -- ..CENSUS TRACT..._...-- ........... .... Owner's Name.. . ... 1 .....psA) ..........Phone.... .. Address..----... v�rr��./ MIM64 2LC:.}r............... .... ........................:.........City ------- . .....:.ZiR O� Contractor's Name-.-...7f!7 Rd21SF{ Sal(�5-----,--- - - License #_ �'1... .T Phone.... - .h �....... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ M del.-❑ Other_ .).(........... ------•'h-------•• Number of living units:........ _..Number of'bddr.00ms-.= 4...Garl?age Grinder.. .....Lot,Size_....1 :x ----••-- -- L t; ` Private Supply: y Water Su I Public S stem and name..:.. ---- ----------------------- - :..... . ---------->--- . .- ✓ ` � Character of soil to a depth,of 3,feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Cl'ay Loam ❑ Hardpann Adobe Fill Material._ _... .. If yes, type.....- _.........!'� (Plot plan, showing size of-16t location of system in relation to wells, buildings, etc. must be placed:on reverse side.(NEW INSTALLATION: (No septic tank or seepagepit permitted if public sewer is available within 200 feet,) 7T ` PACKAGE TREATMENT ( ] SEPTIC TANK[—]-�---�—Size _.._-:—^--..------..---- -,.:.,:------ •---------- ----Liquid Depth.........-...... ......... Capacity...... .. i- ...Type atri � : � ;7Noxy Compartments -----•----... .....Foundation---__- -- ... Prop. Line..-----.----.- -1 Distance to nearest: Well-------------------- - ------- LEACHING LINE [ ] No. of Lines - -- - ------------ Length of each line Depth Filter 1 ToToI.-Length ...._.---- --------------I_.... ----------------- - ----- D Box____ -....;.Type Filter Material........ p - } Distance,to nearest: Well... = ~Foundation--------- - {---Property Line.....----- ...... . �r,f�, SEEPAGE PIT [ ] Depth------------ --Diameter-.-------..--.-----.Number-----------.- -- _-- - ----- ,Rock Filled Yes ❑ No ❑ a I Water Table Depth--------------------------------- ---------- ---.Rock Size- ..... Distance to nearest: Well---_-----�------------------ .----Foundation_... ....-- -;.:.f. .Prop. Line....-------.-_----------- q REPAIR/ADDITION (Prev. Sanitation Permit#--------------- .. . ........---..Date-----------_ ........... ] Septic Tank (Specify-Requirements) _ ----------------------------- ...... -1------------- ---- ------- --------- `: ...-- ...-- .......... 41 !'/�� Disposal Field {Specify Requirements)---. f .--- S _ ___ _ --------------------- .............. .. . w ..... �. --------------------------..... ............. ------------------ ... .. ..._.................. .........---............-_. ......................................... k . - .... f {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 rand 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 to become subject o Workman's Compensation laws of California." k Signed---------- ----- -- - ------ - Owner Title............ ..-ST- a r>- ---.----_-. . BY---------- ------- -- -- ( �� 1 I (if other than owner) ' FO DEPAR MENT USE ONLY APPLICATION ACCEPTED BY---..... ........--- -DATE . --- ---- - ------ ------- ------... !tom^- DIVISION OF LAND NUMBER.-...._.--_ .-... .-......---- ADDITIONAL COMMENTS.- ........................ _ ------------ --- .------------.....-------:------_.-- ------- .---- --.--..Date ...._S .�..-�T - .. ........ Final Inspection by:-- - -------------- eH k3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV, 7/7e su