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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------ (Complete in Triplicate) Permit No.�_gc-Z" , ----------------------------------------------------- Date Issued---g:r._g-. ----------___--------_----------_------------------ ----- 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 Ordi e No. 549 and existing Rules and Regulations: ..��77 / JOB ADDRESS/LOCATI N---- 4 .SCG`� '---/C- --------------------------- Owner's +(' � - CENSUS TRACT ------ Owner's Name. P�C;OPJ`t� � ---- -- - Phone Address -- ----- ----- - ----- -------/---�-------- -Ci z ----------------------------zip------------------------------ Contractor's Name-_ � � - --- --------- ---------'S�---------License #..3Z�' ----Phone- - ---------------- - Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ / Motel ❑ Other..-_.,--------- -------------- Number of living units.-.---- -------Number of bedrooms.-3----Garbage Grinder------------Lot Size.__ ----___._________________ =---___..._. ..__ Water Supply: Public System and name--- ------ ----------------------------- ---._-.Private Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay E] Peat ❑ Sandy Loam LJ Clay Loam ❑ Hardpan (Adobe ❑ Fill Material............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 seep pit permit if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Size. _d_/�_______x �.___ _�-_- Liquid Depth_ -------------------- Capacity_�. e0--------Type P -��Matarial__ �,--..._.__No. Compartments --___________________. istance to nearest: Well-----------_. Foundation-___y1'� -~-.Prop. Line.-------- __ ___________ � _Total Length __.1--2 -_ LEACHING LINE [ No. of Lines ...__.______________Length of each Fine,._____ �___ -_.___----------- 'D' Box_/-__..-_Type Filter Material--- _-____Depth Filter Material-.-_11--��--------------------------_ ________.-.--� Distance to nearest. Well---- ,._.._..Foundation.-- G � -�� Property Line.--� --- ---- ---- -tl' SEEPAGE PIT [i� _ Depth____-r-- -Dia meter..___�_�_��_Number--_____��` '_______________ Rock Filled Yes ❑� Water Table Depth.-------------- Rock Size ` 3 V Distance to nearest: Well-------__'14�%___.. ___Foundation .Prop. Line._j REPAIR/ADDITION {Prev. Sanitation Permit#---------------------------------------------------Date----------------------.-----------------------) SepticTank (Specify Requirements)--- ------------------------------------------------------------------------------------------------------ --- ----------------------- -------------------- Disposal ------- ---------- DisposalField (Specify Requirements)---------------------- -------------------------------------------------------------------------------------------------- ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- --------------------------- ------------ -------- ------ ------------ ------------- ----------------------- -------- {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, 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 permit is issued, I shall not employ any person in such manner as to become subject to Workman's ns tion law:lw f California." Signed--------------------------------------- ----- ---� -----------Owner By------ --------------------------------------- ------------------------------------- ---- ----Title.- - --- - ---- -- --------- -------------------------------- (If other t an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - - ------- --------------------DATE 7 - DIVISION OF LAND NUMBER --- -- ---------------------- - - ---.DATE.-------------------- ADDITIONALCOMMEN( S- ------ - ----- ------------------------------------------------- -------------------------------------------------------- ------------------------------------------- --------------------------------------------------------------- - ------------ ----- -------------------------------- ------ ----------------------------- - � - . -------- - --_---Date---Final Inspection by: ------- . -- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M