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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No._" �."_._..._____ Date Issued------------Y...... ____________________________ -------------- This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin Local Health'Di trict fora permit to construct and install the work here_ in described. --,This-application-applicationin compliance with County Ordinance No:549 and exisfing Rules and Regulations"— JOB ADDRESS/LOCATION__= - CENSUS TRACT---------------------------�. Owner's Nam = _ - = -----Phone j 4 IF Address- Ie ��---- -- ----- - }_,.City- _ --------------------Zip------------------------------ Contractor's -------- -------------------Contractor's Name------- ----------- ------Licensed#L -------Phone---------------------------------- �.. _ Installation will serve; i r Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court �] __ .:,� .r ... ,.._....�. . .,;. .. Motel ❑ Other_ "7Jz��.�- - ' .z Number of living units:----?�--------Number of�bdroomsr_- __Garbage Grinder_____._____ S ; --------------- --- --' --- Water Supply. Public System and name _-:,-.-_:_i.-__-------- --.- ------ ----------------.-=--- --=---------.--- ., _ ---- -- ' .Private [J Character of soil to a depth of 3 feet; ! Sdnd E] 'Silt j] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ ' ;Hardpan Adobe❑ If yes, type = i Fill Material____' .. t (Plot 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 withili 200 feet] t 1 1 PACKAGE TREATMENT [ ] SEPTIC TANK `[s]"" Size-_ -"-__ " . '--- -- " ' Y Li'qui'd'Depth.: ----------- `--- -- �.- --!Type `----------M -- Compartments j ------- capacity---- T e__ aterial Y No. C I]istance to nearest: We11.:-------------------- --- ---___-- Foundation-.- -----------.Prop. Line-------------------------__. LEACHING LINE_ [;] No, of Lines--------------- Length of.each ling .__. --------------------Total Length---------------------------------------- `D' _._. __ .__ __D' Box Type Filter Material-_ ------------Depth Filter Material- ------------------------------- ----------- Distance - _ --Distance to nearest: Well_`_.____._ _ _____Foundat'i" n-_ ---- --- -- roperty Line r. ..� . . .: __. --- --- ------ ------ SEEPAGE PIT [ ] Depth------- ---_._ Diameter.:_. Number __._ Rock F111ed.. Yes ❑ No Water Table Depth i 4 -- ---- ------------------------- ------------Rock Distahce.toneaesf: Line.----- -------------------- Wel) ." -___ Foundation ._. _____________ Prop. Line._.__ --------------------- REPAIR/ADDITION ° __ _.__ __._. ' REPAIR/ADDITION (Prev. Sanitation Permit#- ------------------ - � . --- -------- -- ----Date----- -------------------- -- --- l Septic Tank (Specify Requirements),—L.---= --- ----------------- ----- -- - - -------------- --.---- j * . Disposal Field (Specify Requirements)=....---------------- _ .. ---- ------ f ' X .T' n s ---------- - ------------- ----------- - -------- - ------------ - --- ` --- Z [ ----- ----- ------ ---- ---s ------------------------------------------------------- (Draw existing and required addition on reverse side) I 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 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 to Workman's Compensation .laws of California." t - � Signed--------------- ----- 7: Ownerj BY 1 ----Titled ------------------------- (If other than ow6er] ' F FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY --- --------------------------------------------------- -DATE.- - -- ---- ----- DIVISION OF LAND NUMBER------- --------------------- -- -------------- -------------------------DAT- E------------------ •------------------ ADDITIONAL COMMENTS --------------------- ----- ----- --------------------------------- - --------------------- ------------- --- ---- --- -------- -------------------- - ---= t ------------- - - ----------------- ---- -------------------------------------- ----- ------- --- Final Inspection by ' '`== Date r- g _._ J EH 13 24 SAN JOAQ IN LOCAL HEALTH DISTRICT F&S 21677REV