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FOR OFFICE USE.- APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: -----`--------------------------------------------------- ' (Complete itt Tripitcate) Permit ----- - _ _--- --------------------------------------------------------- ------------ --------- This Permit Expires 1 Year From Date Issued bate Issued_f/_4_-_7_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. F This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: �J JOrB ADDRESS/LOC TION_-_. / ,� - �-1 . - fA-� <- m--- - sS-- �4�--A1�.- .CENSUS TRACT------------- T -- --- ------ - -- Owner's Name.. ----------- -----=- - ----- - o ��a� �' Ph Address _P /:.__ ' C -- -- --- --- -----CiC �+ -------- �i / - pT1 ------ Contractor's Name_'-' -_ � c r�.'t -:License # - ` ---Phone___f�z---- ' i+ Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ 6 Motel ❑ - Other--------- ----- ---- ------------------ Number -- ------Number of living units----------- ------Number of bedroom s'__11____-Garbage Grinderkd----Lot Size_._,.-----_i If? _- Water Supply: Public System and name--------------------------------_ --- ---- -- ---- :.�.- . - - - - - -=- ------------------------ -------------,--Private Character of soil to a depth of 3 feet: Sand [:: Silt❑ °Clay ❑ ; Peat E] Sandy Loam E:] Clay Loam Hardpan Adobe ❑ Fill Material- ...... yes,Y type---=-•---- --------------- (PI't ------- - (Plot pian, showing size of lot, location of system in. relation to:wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: [Nonseptic tank or seepage pit permitted if public sewer is ova ]able within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKr]' - . Size--------------- ��--�!$ --=------ ------Liquid Depth__"L_._-�"'�------------ Capacity ----- D4 Ca acit --Type --- ------------------ --- 6 p Y Material-_. :• =-No. Compartments --=---= t Distance to nearest:.Well__-_--_ ��--�- ----- - .- -----Foundation.-_--•=-- -------Prop. LEACHING LINE: � - f 'r r [ 1 No. pf Lines___-__' __-=----:- -_-:Length of each line.----.�Q-------------:--,Total Length._-,__Apo----------- r D' Box_____--____-Type Filter Material'_ 6s---__-Depth Filter Material------- _ Distance to nearest: Well--- - ---------------Foundation_-- --( -----T--- Property Line_--_-±------------------------------Cl SEEPAGE--PIT' [ l - Depth_. = Diameter r---- ---Number- -_--- 0 t V , _ Rock Fillet! - Yes ❑ No ❑ p., Water Table Depth---=-____--:_:__-____fit_- Rock Size,__ 9 ' Distance to ne6rest: Well- -=- ------- ---`------ - -----------'Foundation--_------= -- ---_- Prop, Line---------------------- REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------- ---------.-------Date --_------,--::--_----- r ) ! Septic Tank (Specify Requirements)------ ------ , Disposal Field (Specify Requirements):_.-.- ------------- ----- ---------------- --------------- _ - -- --- ------------------------ ------------------------ - 4 i p ' p existing , p ----------- --- (Draw and required addition on reverse side} j, I hereby certify that I have prepared this'a'application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of they San Joaquin Local Health District. Homeowner or licensed agents 4 signature certifies the following: i .k "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 becomeubject fo Wor an s Co pensation• to of California." Signed_ .e - ---- - -- -:. �-------- --------- ---- ----Owner BY- ------ ------------------------------------ Title e ------ ----- -----=----- (If other than owner) -- FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY__ µ - -------- -------= = DIVISION OF LAND NUMBER _--_:'_______________ -----------=-------- ---------- ------------- ADDITIONALDATE COMMENTS------------- - ----------------- ------------------------------- --------------- -------------------------- _ f e = J {-- ------------------------------------------ -- - ------------------ - - ----_ - " . i X _ `"-------------- ---- --------------------- r---------- ----------- -------------------------------- ----Final Inspection by " - a' ------------- EH 13 24 --------- ----------------------- - ---- -•----- ; Date: SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M