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C: : AOR-OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------- ----- Permit No.-_.7.[__� I__ (Canrplete in Triplicate) Date issued_.f-{�".�� This Permit Expires l Year From Date Issued r II Application is hereby made to the San Joaquin Local Health District fora 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- v-- -----P�----------- - --- -..........CENSUS TRACT_----- ---------- ------------ --------- ---- -- ----------=-- -Owner's NamePhone--- Address----- hane._-Address---- ---- -------------- -------- ------ -- --- '�--e ---- ---- -- - -- City----- - --Zip- Contractor s Name------------------- - �_ _ _ ______ ---License -----Phone-- 7 ° Installation:will serve: Reside ce } � Apartment House❑ Commercial ❑ !Trailer Court ❑ � 1 Motel ❑ Other--- ------ ---__ �. Number of living units:_____-_ __Number of bedrooms--__F.__ Garbage Grinder------------Lot.Size-__"__,� "-_-----•- -- - Water Supply: Public System-and n'am�e---------: . _.-:-- ------------. --::-- .... } ' ".F Private , i , s Character of soil to a depth of 31�eet- Sand ❑ Silt❑ Clay ❑ Peau Sandy Loam ❑ Clay Loam ❑ Hardpan P�4_ Adobe Fill Material-_.__.___---If yes, type---i---------- __________________ ; (Plot plan, showing size of lot, location of system in relation to wells, buildings,ete. must be placed on reverse side.) o NEW INSTALLATION: (No septic tank'or-seepage .pit permitted if public-sewer is.ailable^within 200 feet,) r jI, r r Sys Ir -- PACKAGE TREATMENT [ ] SEPTIC TANK } 1' t ize--_. '=_X :_r ': '' _•;_________Liquid Depth.__S ____-_______ Type.__ :----Material_ _ No Compartments ------------ Capacity --- -- �:L�l I� Distance)'to nearest. Well ��_1_:_ of -,F- ---�.�. .1=oundati;on.-`-----�� ---=----•:Prop. Lin -- -- ------------------ LEACHING ----------- -LEACHING LINE No. of Lines_..____-_ -----------------Length of each line..__-___�.�; .___.,Tatal Length..__A4__-___„_.___-------------- D' ~ Box,):__ ; Type Filter Material__ . Depth Filter Material._-_ __ __„__- ------ Distanc�ie to nearest: Well___LP-0---------------Foundation -�_ _-1 ;--�.�-_.�_�_ r.1--.Property :Line _ ----------------------- SEEPAGE ---__ _ --- - SEEPAGE PIT DePth._� �_---Diameter-------3-3 � - Number_ --------------- ----L1 ”- Rock Filled Yas No-❑ T Water Table Depth._-- ------.----Rock' Size' -- ) - 1 � m 4 � . Distance to nearest: Well--_------�1__�_._________ :�_ _---- Prop. Line---T.�-_ # Ij Foundation _ REPAIR/ADDITION (Prev: Sanitation Permit#------ -------- Date----.____ :------- _------� __-"__") - 10--- Septic Tank (Specify.Requirements)---- --------=------------ =. =_ --------------= I------ -- ---------------= = Disposal Field (Specify Requirements)---------------------- ---------------------`--------------- — _ ' ---------- - _ --_--------'------- - --- - - - ------------ ------------- ` = -- . --------------------------- ( I;. (Draw existing and required addition`on reverse side) 3 � 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:1l. ] `: "I certify that in the performance of the work for which this permit is issued, ..[ shall not employ any person in such manner as to become, subject to. Workman's Compensation laws of California." Signed -------- ------ --- ------ ------ ------------- Owner - _ $Y --------=- - ------- i--- - --------------------- --------- - Title �1 ------ ------------------------------ I f other than owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__. + 4 -------------------DATE." DIVISIONOF LAND NUMBER:__--I- ------ -- ------------- -------------------------------- ---------------------------------------DATE---------- ------------ ---------- ADDITIONAL COMMENTS----------1�'__-_-- -------------------------- - ------------ --_-_- -----------�M----- -------------------------- = .----------------- --- -"---------------- - - - - - raSAN --------------- Final-Ins ection bY�------------- -p--- ------ ------------- -- - - ----- =Date:--- EH 13 24 JOAQUIN EALTSTRICT F&5 21677 REV. 7176 3M