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FOR OFFICE USE: FOR OFFICE USE: ^� APPLICATION FOR SANITATION PERMIT ----------------------------------------------- � y (Complete in Triplicate) Permit No. .. _____ Date Issued.�' _.�. ---------------------------------------------------- This Permit Expires 1 Year From Date Issued r[527.a-v1 eA l a camas :U0 an oa Application is hereby made to th quin 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 existing.,Rules-and Regulations: JOB ADDRESS/LOCATION p_-- _eQ_. _ -9-"Vo -�� .__.t CENSUS TRACT'.--------------------- Owner's Na -1`3_ "' '� -- ---�-- ---------------------`----------------------_-�. :Phone Zi _ 3 ------ C.0 Address { ` �.... .... ....... /►'! P Contractor's Name-- - -°✓�--- --y-- -----ply--?+- --C�_j..Ys- -------------------License #_ I> 'C2 -`]-----Phone_3-a` - �.!�.7--+f------ Installation will serve:W Residence Apartment House Commercial Trailer Court ❑ P ❑ ❑ £❑ ' Motel] Others - ------ Number of living units:-------`------Number of bedrooms':__�.__Garbage Griner----- ____Lot Size__________________________________________:_.__.___-_._... y ..'-:---- f, ----------------Private ®' Water Supply: Public System and name____.__.______. Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat[] Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material'..______..Jf yes, type---<.............-______._..._ , (Plot plan showing size of lot, location of system in relation.to wells, buildings, etc, must be placed on reverse side.] NEW INSTALLATIQN: `(No septic tank or seepage pit permitted if public sewer is available within 200 feet,] a' PACKAGE TREATMENT [ ] SEPTIC TANK [I Size------------------- ----r ------------------Liquid Depth._________._____.____ i Capacity-.(Y¢__c5_---`Type. •ltic--- Material:_ _�1QI_)�_No.-Comparrt�ments_!------- �J I - -' �� ` Distance_to nearest: Well.___- ___- ^'D___________________Foundation_ __ Prop.Line-'�` ._�............ LEACHING LINE [ ] No. of Lines------------_ _ ----.Len of each line [ .__`__ ___._.,Total Length ______1?10 --------------- .'D' Box__.._/-_._-Type Filter Matericill-2 aG! Depth,'Filter Materiiil _ Y#=f -------------------------------- ___._._-_ O Distance to nearest: Well/4. --- _____FoundationProperty Line__ __,_____________________�._- SEEPAGE PIT [ ] Depth- ------ -------Diameter-3------------- ----Number---_----------.-- ---------- Rock Filled Yes No ❑ Water Table Depth i� ----- --- -----. __ - _.Rock 'Size`---------- --- -------------------------- i . . ,tance'to neatesf: Well Foundation - - .Prop. Line REPAIR/ADDITION (Prev. Sanitation Permit#/-- --------------- ---- ----- -- -- =-------Date.'---------:- ::-----------------] Septic Tank {Specify Requirements]- = - --------------------=-----------=-----=---------------------------------------------------------------- --- ---- Disposal Field (Specify Requirements)-....-...-,.-- ---- ------------------------------------------------- -------------------------------. -------------------------------------------------------- ------=--------------------------------------------------------------------------------------------------------------------------------------- ,. 4 (Draw existing and 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, Stay;Laws, and Rules.and Regulations of the San Joaquin Local Health District. Home owner or licensed agenis signature certifies the following: . i "I certify that in Lthe'performarice of'the work for which this permit is issued, 1 shall not employ any person in such manner as to become sub' ct toF4�_ rkman's Compensation laws of California." - i Sighed ��s may- - --------- --Owner ,,. , ._. I lid BY------- = ---------------------- ---- ------- i = -------- -- -- Title--------- -------------------- --- -------- ------ ------- ---- ------- ? A Of other than owner] : -� -,FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_._ c1------------------DATE. : DIVISION OF LAND NUMBER--------------------- -------------- _ --------------------------DATE.------------------------ ----------- ------- ADDITIONAL ----- •- ADDITIONAL COMMENTS-------------------- ---- --- ----- -- -- -- ------------------- --- ---- -------------- i - ----------------------•----------- -------- -_ --- ------------------ - - --------- - ------- --- ---------- ----- ' Final InspectionbY --------- _ _,.-= - -, Qate_ ' _ f ------ mss v------- _---- ia`a 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M