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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PER 1T i' (Complete in Triplicate) Permit No...... ....... .___. ` .�.__ ......... •-•----••----- - This Permit Expires 1 Year From Date Issued �' Date lssued_.�. Application is hereby made to.the San Joaquin Local Health District for a permit to construct and'install the work herein described. N This application is made in compliance with Coun y Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION--- -T-.. ..................................CENSUS TRACT_----.-_-.--.---.---.----.-.-- Owner's Name .- ?".-. --- . h �.................... ----_...P one...... --•-- ....... ......... 4 Address........ �.�. �. ..- City... Zip Contractor's Name..-.-- -.. .-- _-- .. License # -- -- - Phone... -------- ��.. Installation will servTe: Residence Apartment House E] Commercial ❑ Trailer Court E] r M b fel ❑ other----------...................... ... [ Number of living units:_.......'-------Number of bedrooms..-- Garbage'Grindar.........__Lot Size.................. ... .. .. .........:.................. .. Water Supply: Public System and-name:: ,�,::.::_... c�.- �. _- .__77�__ _ ....... ....:........Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑; Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material__ ___ yes, type (Plot plan, showing size of lot, location of system in relation fo wells, buildings, etc. must be placed on reverse side.) --�- NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,[ . (' PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.....11k.1k.` _ -Liquid Depth---4/. ....\-j....... capacity./--�. .�....Type.-�----- --... Material-- -.-- No. Compartments... �y`-_- i Distance to nearest: Well....... L. Foundation._.J.6:............Prop. Line.... .......... .... LINE [ ] No. of Lines.. Length..............Len th of each line_... g I/-/. ---------------- 'D' - --..-.---.-. -.-� LEACHING g .----------- Total Length . - 'D' Box..../......Type Filter Material___. . ��._. Depth Filter Material_. .-- - �� Distance to_nearesh.Well._p Foundation- _ Property:Line [ ] f De}t�...liow, .Diameter.___ .y.x-Number_.__:_-pn,- `__'_______ = Rock Filled Yes LV o Water Table Depth------------------------- --.._.__,Rock Size........... .................................... Distance to nearest: Well...-.. ... ...____...Foundation-----------------------____Prop, Line..............__....___... w —T-_ ] REPAIR ADDITION (Prev. Sanitation Permit#-�---------------'�- ---- -- - ----:Date-�_-,--..--------------- -------- --_---- _. Septic Tank (Specify Requirementsl .............. •�- Disposal Field (Specify Requirements)- -- -------- - = --- --------- ----------------------------------------------- ------------------- fA # - ]Drow•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: "1 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 Co ation laws of California." Signed_. -Owner By---------- -- ----- ------ ------- --- -----.Title-- ._...------... ------. ( f of r han owner] FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY. ------ - .- DATE -Y--_3� _7f.................. DIVISION OF LAND NUMBER.. . ........ DATE.. ......... ........................ ADDITIONAL C M NTS /�°"-_... -------�...... . ...... - - �--- -----------• --..._--------------- .----- ------------- ------- -------- .................... ----I--------___------------------------............ ............. ..I ----------------- ------- Final Inspection by:----------I................ ...............................------- - �� .. ...Date - ...... EH 13 24 SAN JOAQUIN LOCAL HEAL(T14 DISTRICT F&5 21677 AIV, 7176 3M