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FOR OFFICE USE. ' FOR OFFICE USE: APPLICATION FOR SANITATION.,PERMIT -----------I _ Permit No.'-[� '.. ..5 (Complete in Triplicate) ----------------------------------- ----------- d �} 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. [ �h ' �y ks and Regulations- � n � ... . This application is made in com Bance with Count Ordinance No. 54 an existin Rules ( PP � P JOB ADDRESS/LOCATION..�---�-�-1..,__e - - -------�----------- ------------------ -------- -- ---CENSUS TRACT ----PL--...------------ ------ ii Ph rl ane Owners Name ---------- ------ Address-....-- '- -------City - -----Zip--- _ .. ` Contractor's Name-. ---- ---- a' r ' ------ ------- License # ,32:8„- ----Phone---------------------------------- Installation will,serve: Residence [Apartment House.E] Commercial ❑ Trailer Court ❑ ' ' �� .. . .... Motel ❑ Other------- ----------------- Number of living units:. :.- ---.Number of. bedroams...U-__Garbage Gnndex :-,Loi,Size ---f ..- _....._ __ ....... y ,.. Water Supply:.Public S stem and name .. -- - -------- ------ ..-=--- - -- -- ---- ---------------.--Private [� . Ni ': Character of soil to a depth of 3 feet: ' Sand ❑ Silt❑ Clay ❑-:7s Peat❑ Sandy Loam IClay Loam ❑ i Hardpan ❑ _ Adobe.❑ Fill Material--f........If yes, type-==----------------------------- (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 se page pit-permitted 'if public sewer is available within 200 feet,) 4 PACKAGE TREATMENT [ ] ` SEPTIC TANK" [.] Size-------X_/�--- �/'-----=----------------------------Liquid Depth.' ---------------------� ' Ca acit �6a O Type- -- Material.--:- -. No. Compartments----.....-._`---------------- p y------------- - - - �s� `' S`r Distance to newest: Well..`................. --.....---- Foundation___...__ _ ---Prop.-Line:,_------"__...... LEACHING LINE No. of Lines_:------3-- -----. --.-Lengt.h of each line----_.._-�d.�--- .Total Length ��_----. ...._Type Filter Material-....-S/ -----Depth Filter Material..`.-- 1`7.111 -------- .. Y t { D' Box . Distance to nearest: Well �. . .: ` Property Line-: SEEPAGE PIT [ } Depth_-_ ___- --_Diameter------- -----------Number ndation---------------- . • --- ' . . 7 Rock Filled�Yes:❑ - Na ❑ ------------------------- • 1� W' atei r Table Depth-------------- ------ ---i--- ---- -----------Rock Size- - --------------- histance.to nearest: Wel ------------ -------------- --Foundation--------- -------Prop. }L ine-- --------------------- REPAIR/ADDITION (Prev.-Sa n I itation Permit#-- -----=-- - --------------------"-----=---- -----=---=-- - _------------------ SepticTank (Specify Requirements)-------------- ----- -=--_--------------------------------- -------------=----------- ----------------------------- - ----------- ------ ----- Disposal Field --------------- .(Specify Requirements) = ----- i-------------------------- ---- ------- - ----------- ---------------- = i -----.---= ------------ (Draw existing and required addi tion on reverse side) I hereby certify that I have pre ared 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 ich this permit is issued, i shall not employ any person in such manner as certify that in the performance of the work for wh to become subject to Workman's Compensation- laws. of California." Signed--------- ------- ------=--- -------------- -- ----�- -- ------------Owner- . .- .. _ - •- , �I' Title . BY--------------=----_--------'- ----------- ------ - _ If o' . ..'.FOR � i { other than owner} DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY --------------------------------------- ----- - - -DATE DATET17 DIVISIONOF LAND NUMBER-------------------- --------- = DATE---------- --.------------------- ---------------- ADDITIONAL l COMMENTS---Ii-M------------------------- ----- -------------------------------- ---TM-----_--------------------------------------------------------------- -- ---------------------- -------------- ------ --------------- ------------------------ T . 11 = -----------'- - - --- ------- - ---- -------------------------------------------------------------------- --------- - -L :-7) --------- --- - - --- Final Inspection by:----- -- - - '"r------ -----------_Date-- EH 13 24 SAN QUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M