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FOR OFFICE USE: _]� �� FOR OFFICE USE: V APPLICATION FOR SANITATION PERMIT ---- ---------------------------- (Complete-in Triplicate) Perr�art, No. -. - - --------------- -- --------------------------= ---------- Date Issued- _- :. --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San 'Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordino ce No. 549 ynd existing Rules and Regulations: ; JOB ADDRESS/LOCATION 3 f - _----- ----- ------------------------------------ -- CENSUS TRACT -- Owner's Name -- ------ --- - ---------- - -.-.1------�s................ - = Phone----- ^--- ->------------------ Address.----- ----- �, City !/ t. - ZIP Contractor's Name- ,. ''"7K.`._'&._License #--- V-2-2w4wPhone------------------------------- Installation will serve: Residence Apartment House.❑ Commercial ❑ +Trailer Court E]s ' Motel ❑ Other------------- ---- -----' --- -------- -:-:-� _ r- -- Number of living units:_-_-_-____Number of bedrooms___ ...,Garbage Grinder___- _:_Lot'Size------------ZG"` '"0" '"' _-_.____-.--_ Water Supply: Public System and-name-- -------------- ------ "------- F-= ------------------------------ --r ----------------------------------------Private [d� Character of soil to a depth of 3 feet: Sand E] Silt E] 4 Clay ❑Peat❑5andy Loam [ Clay Loam E] # Hardpan EJ Ad be E] . .Fill Material --__, -If yes, type----------------= = __- : _.�_ t —„► (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc. :must be placed on reverse side.) -� NEW INSTALLATION:A '(No septic tank 'or see age pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] -SEPTIC TANK j!J ' Size- ----' ----1�-_- ---_--X--s=----------------Liquid Depth._-- -------------- --- a, i - CapacitY---1.P-�----_-_,TYpe-- ------------------ Material__ _�- -No. Compartments------ - Distance-to nearest: Well-=---=------------ ----- -- ._ -- Foundation_:-----/Q__. --Prop. Line------ -------- --- LEACHING LINE [/ No. of.-Lines......... _____________:_.Length of each line,.,,__._,_ _� fi"�----- Total Length.--_.._L6_P_ r_ ---_------------? 'D' Box_.;_. ------ Filter Material ------Depth Filter Material-----1_ --"------------=------------- -------------- -ti ;y Distances to nearest: Well------DRQ I ----_Foundation-- `-_____.___.Property Line---_ 011'V_7,1-------------- �1 l -26 [ Depth.---• -�? r_.�---.X_!�_--Number----------- ------------- Rock Filled Yes [ No E] i Water Table Depth---------- ---------- ----------------------- Rock Size----f f ' �--------------- Distance to nearest: Well----------/._a_a__Ae'______________-Foundation.____-1,a_� _____.Prop. Line--_-_-� ___.__ REPAIR/ADDITION (Prev. Sanitation Permit#-"---------- - -- -----------------•--.-------Date---------- ----------------------------------_] Septic Tank (Specify Requirements): _- ;------`------- ------:=---------------------------- ------------------------------------------------------ ------------ DisposalField (Specify Requirements)---------- ----------- -------------------------- -------------------- -------------------------------- ----------------------- ---------------- = = ---- --- --------------------------------------- ---.----------------------------------------------------------.---------------------- ------- --------------------------------------------------- ------- --------"----------------------------------------------- ------ ------------------------------------------------ ---- ---------------------=--- ' {Draw existing and required addition on reverse side) " I hereby certify that l 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 4 signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's. Compensatioa'li3ws of California." Signed---------=--------------------------------------------------------------------------- Owner Owner By-t---- ------- ---- --= --- Title ---------------------------------------- -------------- i (If'other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----4f ---------------------------- ---------------------------------- DATE �J --------- ---- --- DIVISION OF,-LAND NUMBER...-.:-------- --------------------------- --------------------------....DATE---------------- ADDITIONALCOMMENTS---------------------------------------------------------------------------------- ----- -----a"------------------------ ------- ------------ -------------- ---------------- ---------------------------------------------------------- ----- - ------------ -------------- - ----- ---------------------------------------------,------------ .' ,. ----------------- er - - -- - - ----------- - ----- - Final lnspecfion by: Date = EH 13 2d SAN JOAQUIN CAL HEALTH DISTRICT F&s 21677 REV. 7176 3M