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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 'S. i ---------- =: ---------- - --- ------------- x (Complete in Triplicate) Permit No.�,�.............. .. p ----------------------- ----------------- -------- • -- Date issuei d-�-c�.7`- This 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 No. 549 and ex'Sting Rules and Regulations: JOB ADDRESS/LOCATION.__.__4�.7.,- .....CENSUS TRACT....:........._..- .. Owner's Name. - .-- ................. - ..-- - Phone... .. ��3. X397 .Ci ...... Address- -� -�oZ- --... .-- - - ------- -------'-...... - tY - .. . .... . - -- -----------... �/� ._...License #-310,.E-��' Phone....'/4.-�•d�/.......- } Contractor's Name.... ....-_ (. .__... I Installation will .serve: Residence' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-_--- ------------- -- --------------------- Number -Number of living units:.....!......__.Number of bedrooms..�....Garbage Grinder-------- Size_...... ------- ------- - Water Supply: Public System and name.......-.... ........................... •---------- ------------------------ --------------------..-.Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeX Fill Material,. .... ....If yes, type............. : (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 within 200 feet,) '/ , PACKAGE TREATMENT [ ] SEPTIC TANK Si e._.7.x.rrx ----- ----.-Liquid Depth.-::7...--- T� Capacity,La7Q4------Type�/lQ- ...Material_ ----- ...:No. Compartments-------�----------------------� ' 1 �' 7 Distance to nearest: (Nell-_.��Q -- --- - -------Foundation-.-/4- _........-. Prop. Line.... .-_._...........-... LEACHING LINE No. of Lines i ___c-A -- .- --.Length of each line.? ...Total Length ------- D' Box--- Type Filter Material S'./ ..Depth Filter Material.-;.....I ......__ ----------------------.......... Of I Distance to nearest: Well. 44-..- ---- ----.Foundation._.P-4..................Property Line...s-----------------------•- ii SEEPAGE PIT Depth_c75._.._.._Diameter--_3.._ Number...------=�------------------ or Rock Filled Yes ]' No❑ Water Table Depth......... �l�D.. ...... ..-.Rock Size. .3----- ------------------ -- Distance to nearest: Well....{-_5?).... ..... .................Foundation. XDGt......."" Prop. Line REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- .........------Date---------........ .--.-------------------} t Septic Tank (Specify Requirements)------ ----------•----•---:------- ------- --- -- -- . ------------•----------------------------- .....". ----------------- ...........____ ------ Disposal Field (Specify Requirements)---------------------- ------------- ....---- ---....... ----==--------------------------------- -------- --- --------------------------------------- ------------ ------------------------------------- -------------------"------------------------------------- (Draw existingend 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 certify that in the performance of the work for which this permit is issued, 1 shad not employ any person in such manner as I to become sub�'ect,too WE' , ma ,'s Compensation laws of California." Signed---------- �L.�-iA �-. ! ------------------------Owner ., BY -03 �. �"�..- • .... .......... ----------- ---------------- ---------------" --------- (If other than owner) FOR DEPARTMEN�USE ONLY c� APPLICATION ACCEPTED BY....-...` d1. 7DATE 27.. 7---\ I DIVISION OF LAND NUMBER.... .-.-.-- DATE------------------ ------------ ---------------- ADDITIONAL COMMENTS_. LL . .... -- __ ............ -------------- ------------------ -------------- --------------- ----- -------- ------ �:� -- l Final InspecTlon by:.... cry Date..... .1. -. _ .............. ...... EN,13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7f 76 3M