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FOR OFFICE USE: FOR OFFICE USE: APPLICATION F'G'R SANITATION PERMIT (Complete in Triplicate) Permit ------------ This Permit Expires 1 Yea�r,From�'Date Issued Date Application is hereby made to the San Joaquin Local Health District for a per'mT,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 _(-1�fP�' - ---—-------------------- ----- -----•---- ------.CENSUS TRACT- Owner's Name. ---- --- --------- ------------- Address --.---------- Address-- ------- -------------- 4 e- sS n ------ -------- -- -- , _ - City C �- ------------- Zip i Contractor's Name. 3W�- r - _ License ---Phone Installation,will serve: Residence Apartment Hause.❑ Commercial ❑ Trailer Court ❑ -� Motel.0- -7 Other....------'=== = Number of living-units:----------------Number of b droom 2_-__--Garbage Grinder------------Lot Size------14574f'l.--- ----------------------- -- Water Supply: Public System and narne_ _ j -- v'___----_ `�_ Private . —= ------- - ------------ ---- - ----- Character of soil to a depth of 3 feet:f SandQ, Silt ❑`-f )Clay ❑ ` Peat❑ Sandy Loam ❑ Clay Loam �--- Hardpan ❑�, Adobe-;' Fill Material_------'------If yes, ty/•pe-----------------_-------- (Plot plan, showing size of lot, location of s�e_`sfem in1relatidn tow s, buildings,e_tc!must be placed on reverse side.) r NEW INSTALLATION:" (No septic tank for seepage pit Permitted if public sewer,"is'avoilable within 200 feet,) PACKAGE TREATMENT [ ] ' SEPTIC}TANK [ " Size-_=. _ - _� _--_____-_Liquid Depth____, e/- --__6 • Capaify -�"R,� _ T .fi _ O�-- -.--s,---Material--- ----- 2.- � , artmen-- ----- - Dista . -_ ------ ---------Foundation_.___ ------------Pro Line-eto nearest. I - -- ----�-------- �LEACHING LINE . [�K.No. of Feng#h of each line____/A ----_- __---.Total Length. _�------------- - - i:+. _ �.� t�Kj f g f Box. . Type Filter Maters/L� j I��L--Depth Filter Material___a•2 r Distance,to nearest: Well _ f _ _ ________Foundation _ __ts. __..Property Line SEEPAGE PIT W<" Depth.. $7 Diameter.', ----- Number---__._- - +:__---+ - - 1 l Rock Filled Yes��No ( ' I Water Table Depth7f --------------�_-_--.Rock Size._____,._.__ istance,to nearest: Well----- 4�� ` Foundatiori__"1 -------Prop. Line'..--q_ - REPAIR/ADDITION (Prev. Sanitation �------- ��`•--�__ -�..__-y= �:�,-___.Date_-_-______- t Septic Tank (Specify'Requirements)--------------------- � . . . M Disposal Field.(Specify Requirements)-- ----------- ..... . _= ------------------------------ _ �f =- e - -------------------- --------- ----------------- ------------ -------------------- a --------- I 4 ----------- {Draw existing:and requihel�work ec�,addition on reverse,sicfe)l% I hereby certify that I have prepared this application and that will be done--in••acco.rdance with San Joaquin County Ordincincesi: State Laws, and Rulesµand Relgulations"loft the Vait;Joaquin Local Health DistrictHome owner or licensed agents signature certifies the following: ! certify that in the performance of the work'for which this permlt_'is-Fissued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of Cclifarnia.". Signed------ - r----- - --- --- ------ -- eBy- (If other than .owner) ^+ f ~ FOR'DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY )1111 ---- ----------- DATE J DIVISION OF LAND NUMBER--- ------------ ---- --------:--DATE----------- . ADDITIONAL COMMENTS--- ---------------------------- ------------- -- --------------------------------------- ---------- 7 --------------------------- ------ I ---- _ -------_____'- .._ ---- --- - --------------------------- -----------'-------------- t. ,., Y - - ------------- -------- ----__ ----------------`- ------- Final Inspection by---------------- --- ----- - _Date a � EH 13 24 i AN JOAQUIN LO ACHEALTH DISTRICT F&S 21677 REV.