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FOR OFFICE USE: j FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------ - (Complete in Triplicate) Permit No. `s _..__.._ Date Issued--6�1_/6_- 20r\ -------------------------------------- This Permit Expires 1 Year From Date Issued t Application is hereby made to the San Joaquin Local Health District for a-permit to construct and install the work herein described, 1 This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: � l JOB ADDRESS/LOCATION_ /. �__----% __.._ d .__'_�� .-_____CENSUS TRACT--.-- Owner's Name.- --- --- --------------=----------------------------------------- ------------ - ------- --- -- ---.Phone---I .--Q9---4----- t --- Address. � - �� lT�.' ..�`�J---- ------------=-------City ---------------------Zip 19`�3174-- ------- wl Contractor's Name. 4 _---v`' kI"------------------------------ License # - ---�.L.- p�.--=--Phone--7---0.�5- ----- -- F k Installation will serve: Residenceo: Apartment House.[] Commercial ❑ Trailer Court:❑� i ------ --- i • - �. . . :-Motel ❑ Other-------- -- � Number of living units:--/--- ------Number of bedrooms_ ----Garbage Grinder------------Lot Size--- � -- Water Supply: Public System and.'name----------- ---- ° '. _ -_ __ _-__.,,.= -.--.•.- = _, .= ------------------Private _ � j Character of soil to a death of 3 feet: Sand ❑ Silt -Clay ❑ Peat L] Sandy Loam ❑ Clay Loam [] Hardpan E] Adobe rJ pe----------------- ---- --------- (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,] ----Liquid Depth------------------------ PACKAGE TREATMENT [ } ' SEPTIC TANK .----'-------'---------------------------- -- Capacity- --Type--- -------------Material----=---------=- --- -- -No. Compartments---------.- t Distance to nearest: Well--------=--------------....................Foundation------------------_-------Prop. Line------------ --------- _ LEACHING LINE [9f No. of Lines-------1__________________.Length of each line,410_--- ____-Total Length ._..____._��_:____. 'D' Box......)..__.Type Filter Materi4,r� .Depth Filter Material-- 4&we�> --------------------------------- i Distance to nearest: Well_:_ ---Foundation_ Property Line------.�_�?_-_________________ SEEPAGE PIT ( ] Depth----`----- -=---Diameter---------- -=----Number__-'-_--__:-_.___'__---- ____-- _ Rock Filled' Yes ❑ No❑ Disfance�to nearest: Well--------------------- �------------'--- -------Rock Size--------------=--------- =-----'-�'�-----�------ Wafer Table Depth-----------= - c ---------- -- ! i t ' -- -- ` � � � -------Foundation'--- --=�----'--------.Prop. Line--------------------------- ----------- - ----- - REPAIR/ADDITION (Prev. Sanitation Permit#_- ---------------- Date--------------------------------- ------ ] i ;„Septic Tank (Specify Requirements)------ = - - -- ------,------- _----- = = --- Dispos Field (Specify Requirements)-- -------- ----- ------t ----- :.'._. (Draw existing and required addition on reverse side) T ] 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 jiermit is issued, 1 shall not employ any person in such manner as to become :subject to Workman's,-Compensation. laws.of California." Signed _ : _ -Owner ByX ----------------- -------- ------------------------ t - ---------------- --------------------- .----- {If ' other than owner) FOR DEPARTMENT USE ONLY L APPLICATION ACCEPTED BY------------------ �. = --------------------------DATE.------- --- fir ,7�f ------------ DIVISION OF LAND NUMBER--------------- ----------------------- -----------DATE_ ------------ ------- 3 ADDITIONALCOMMENTS `------=------------------------------ _------ =------ ----------------------------------------------------------.---------- -------- •-- -------- -r. r" -- rr = - --------------- ------------------------"'--------------- ---------•-----------------------------------------_ - - ------ ---- ------`--- --------------------------- -`---= --- ----------------=--/------- - -s-- ------------ --- -------- ---- --+ - ----r-- ----- ------ -- Final Inspection by = � '. Date - � ' = ----------------- -=- "t F85 21677 REV. 7176 3M .- EH 13 24 SAN-JOAQUINLOCAL HEALTH DISTRICT ' S+