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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- Permit No--- �~�� (Complete in Triplicate) ------------------------------------ 6 9 - - ------- Date Issued -�----- ------ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for 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: _ ' ._.CENSUS TRACT i JOB ADDRESS/.LOCATION t ' 4 ' Phone--- - -------= ------------------- Owner's = - ------------------ - Name------------- - - -- - . Address---- -�----5- = �,��,/ - � _ , __ City-(l"'' Zip- J ' -- F � ------ 'F ' 2- Contractor's Contractors Name--- - es � License #--- � ---�-Phone-- ---- - --------. ------- - - Installatian_wi{I serve: Residence Apartment House. Commercial EJ `Trailer Court ❑ t .. Motel [� ' Other-.-, Z [ i �1 s UfD Number of living-units---__ `._ Number of bedrooms Wit-__Garbage Grinder._ . Lot.Size__g__.. __ -- X. ti-----------,___ . Water Supply: Public Sys#em and name------------- -------- -- -- _Private €; f Character of soil to a depth of 3 feet: Sand Q Silt❑ Clay ❑ ; Peat ❑ Sandy Loam ❑ Clay Loam ❑ :._ Fill Material If es,tYp r - :------ f i Hardpan ( Adobe ❑ Y e i= t ! (Plot plan, showing size of lot, location of system in relation to_wells, buildings,:etc..must be placed on revui•se side.) NEW INSTALLATION:- (No septic tank`or seepage pit permitted if public sewer is available within 204 feet,) '��• / - / i. �. -- PACKAGE TREATMENT ( ] SEPTIC-TANK [ - Size_-$__.11'�P�______ t-- - -_- ----- Liquid Depth.__.____-------- >--- y , t Capacity /La _ TYPE -Material1xr .. _:-No.-Compartments -------_-;-L--L--- i _= .to nearest: Well_____________S_Q--� ----------------- y- ---�-� p Foundation.- ®' °1-0 ine._ -' -------------- -Distance LEACHING LINE No. of Lines-.------ :-- - I Length_=-`:=• ---- ----------------------- 7 Len th of each line...___ _ ''b_ - _-__-- __ .Tota �✓ g g t 4 -e-. . 3 D' Box__:-+< _.._Type Filter Material'_._ __. -- Filter Material--------Pr -_ - ;-- - :Distance to nearest: Well-------- b_27 Foundation (i ` operty line_.__ ; i -- (� �.� I r'1 ti. w• f f ,Yc o& f # J SEEPAGE ----- PIT [ Depth-------------- Diameter------�--{: - -...Number---:----- ---------y-----� Rock Filled .Yes [ No❑ x i-- y-� -g Water Table-Depth-__-_____- [ �b------ - - ---Rock Size _ '! J t ProLine---------------------------- ------ w Distance to nearest: Well :.- �_Sa------ --- Foundation , p. =: -:`Date = ' REPAIR/ADDITION (Prev. Sanitation Permit#-------------------- ! Septic Tank .(Specify.Requirements) ='-----------=-- ---'---------- --------------- -------------------------- - ------- _,.--_-r.._ T- - . ------ Disposal Field (Specify Requirements)-------`-- ------------- --- --------------------- -------------------- -------------- ------------ --, -------- -------------------------- ---- . ----------------------------------------- --- i -- --------------- ___._ - .__ _._ ._ --------___________________ ______________________________________________________________ __.------ ---------.----------- ------------- _____________ - - ._ _ _ _ _ _ _ ,.._ - -� (Draw existing and required add4ion on reverse side) i 1 hereby certify that 1 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 dial! not employ any person in such manner as to become subject to. Workman's Compensation lows..oF California." Signed -------------------------------------- Owner , v Title By-------- ---- --- _ '1 t (If other than`owner') I FOR DEPARTMENT USE ONLY. " APPLICATION ACCEPTED BY------- _ --- -- - --- ------- ------ ------------------------- ------------DATE = ------ -------------------- -------- - .. DATE DIVISION OF LAND NUMBER __-._ ;_._,----_ . _ ;j.: ADDITIONAL COMMENTS- ---- --- ------------ --- --- ---------------------------------- - -------- -------:---- ----------:------- ------------ ------------- - ------------------------ ----------------------------------------- ------ --------------------------------------------- --. ------------------- ---------------- ------- ---- -- = - - Final Inspection b --- `------Date.-- . EH 13 24 SAN JOAQU LOCAL HEALTH DISTRICT F&S 91677 REV. 7176 3M