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'! FOR OFFICE USE: s., FOR OFFICE USE: SANITATION PERMIT APPLICATION FOR SAN 21&_03 --= ------- ---------------------------------------- Permit No.-- - [Complete in Triplicate) �{ --- --------------------- ----------------- - ---- Issued- ------------- J (S -- Date Issued_ -----------_---._-____-------_ -- This Permit Expires 1 Year From Date Issued I 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 Ordinance No. 549 and existing Rules and Regulations: ' f c� --- - ------. .----- v- -- JOB ADDRESS/LOCATION .-.�7..L------- - --------`--.- . ---- CENSUS TRACT -c-� ! Owner's Name - �t /Ir --- Phones 7- G ' - Address �-'41 �_ � Cit!' _Zip f-30 �6 Contractor's Name---------- - -- -- --� License #_2 ---3zf ----Phone-------- ( rf Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel [I Other----------------->------------------------------------------------------- Number of living units:.,_--_ /- __Number of bedrooms-_�___Garbage Grinder------------Lot Size........ ---`---- --- ------ Water Supply: Public System and name------ ---------- - --------------- ------------------------------ ------------------ ---------------------------------------------Private Charactetiof soil to a depth of 3 feet: Sand E] Silt❑ Clay-❑=-Peat,❑ Sandy,Loam ❑ - Clay.Loam Hardpan` Adobe ❑ Fill Material-- ---------If�yes, type---!----------------- -- -}-._- a: . (Plot plan, showing size of lot, location of system in relation to wells, buildings.,.-etc. must.be,placed ori reverse side.) NEW INSTALLATION: (No septic tank or seepage pit-Ypermittecl if public sew6r i§_dvcrilable within 200 feet) PACKAGE TREATMENT j ] SEPTIC TANK ��Size______ ___/e��----0_141e�------ Depth--------- __----_--_-- L -13 _- . �-Capacity '00-------Type---1-40 --------material----C�LI/e�----No. Compartments---------------------------- f `rt.- p. ----------- Distance to nearest: Well-------------- �__-�- ------:.___Foundation___-__ __�___---_______Pro Line--- -- r Total Len 3 LEACHING LINE No. of Lines---------- --------------Length of each line---------- --- ----;t,---.Total gth.---l._.- -------------,------.--- 'D' Box_____ Type il.ter Material---f61C...Depth Filter Material-____I-_-;- ----.-`---'-------------------------------------- a� .. Distance to nearest: Well --'+ -.Foundation-- -----------.Property Line__w-�7--------------------------- SEEPAGE PIT `j, Depth-.-- ---Diameter___373_-------Number--------3-------------------- t ! Rock Filled Yes b6 No Water Table Depth------------------------ .Rack Size _x! r f Distance to nearest: Well---__------Icz0__r"------------ -------- ---� _-__.Prop,_Line---S---_'f`______-----.� REPAIR/ADDITION (Prey. Sanitation Permit#---------------------------------------------------Date.---__------ ------------------5--1 Septic Tank (Specify Requirements)---- ----- ------------------------------------- --------------------- Disposal Field (Specify Requirements)---------------------- ----- - - ------------------------- -------------------------------------------------------- -------------------------- --------------------------------- ------------------------------- ,- ------------------------- ------------ -------- ------------------- ----- -- -------A-_-----�-"' (Draw existing and required addition on reverse side) 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 Compensation laws of California." \ Signed.----------- Owner - - - -_ BY----------- /� ----.-Title----- ---------- .-- If other than owner) � ��"� r% Jt \ FOR DEPARTMENT USE ONLY ' -- APPLICATION ACCEPTED BY-7__� -- ------ - -- DATE - - _ -._-- - - c ---- DIVISION OF LAND NUMBER ------------ --- -- ------------------------- -- ----------------- DATE.--- -- ---------------------- ------------ ---- ADDITIONALCOMMENTS------------------------ ------------------------------------------------------- --- --------------------------------------------------- ---------------------------- ----- ---------------------- -------------------------- ---------------------------------- -- -- ------ --------------------------- -------------------------------- --------------------- ----- ----------------------------------------------------------- -------------------- --------------- ---- ---------- -- -------- --- ---- ---------------------------------------------------------------inspection by: ------- ----- Date / - EH l3 24 SAN X AQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 inn