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FOR OFFICE USE: a APPLICATION FORSANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit ------------------------ -------------------- ------------ ----------------- � This Permit Expires ('Year From Date Issued Date Issued__. ---__ Application is he by made to the San Joaquin Local Health District for a permit to construct and install the work herein d This applications is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: escribed. JOB ADDRESS/t:OCAT1 NI-.3 of-_.--F-� -------- ------------------- --------------------------- -- ------------CENSUS TRACT----- Owner's Name._- -_ '- /-_s-'t f�r F ------- --- -------- Phone Address------- -- - -- - �--�- � '_" '---f-- --1-- ---- --- .. _ � . _ -------- # ,r� City. Zip Contractor's Name--. . t- 'r - �/� 3 �� Installation will serve: Residence Apartment H License #------------------- ------Phone--. _---------------------- --- !F p ouse.❑ Commercial ❑ Trailer Court ❑ � -�. Motel❑ Other-- = ' 7 I y Number of living units:.....Fl_..______Number of bedrooms--- -Garbage Grinde,r._____*._____Lot Size__`_ _- Water Supply: Public System and na> 1 ----- --- ---- --- --- - ---------------- -------- s - _-.----------Private Character of soil to a depth of 3 feet: SandXj Silt❑ Clay ❑ ' Peat ❑ Sandy Loam ❑ Clay Loam ❑ i Hardpari❑ Adobe❑ Fill Material_ _ _If yes, type_ ___________________._ - - f (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 seepage -pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT (;] SEPTIC TANK [�']" s Size _$' ""` n a F i - - -- - ------------------- ---- -----Liquid Depth.--------- I [ Capacity-------------.........`Type- ------=---------''Material---' No. Compartments - ,i � . Distance to nearest: Well.- - =`- -- - - :- =Foundation tea- prop. Line 3 LEACHING LINE [ ] No. of Lines------- ---------------_ -:.Length-of each line.----------------------------------------Total Length,----- --------- 'D' Box------------Type Filter Material _____._-°______--Depth Filter Material__ __I__ ________._______ __ _ E ---- ---- - Distance to nearest: Well- --------------------._f ,. Fo`undation--------------------------- ___ ____________ ____ t Property Line-------------------------- SEEPAGE ._ _.___ -_. __.SEEPAGE PIT [ l] Depth,_"------------Diameter....I--------------Number-------------------------------- Rock Filled Yes ❑ No Water Table.Depth------------------------ --------- Rock Size------ --------------------- Distance --------------------Distance to nearest: Well---------------------------`-__--------, _-Foundation--------.-- ---.---_.---- Prop. Line---------____-- iI --_______--__- REPAIR/ADDITION (Prev. Sanitation Permit.#_-._____._.__...____._ ----------- - -----------Date-------"-- ---1 Septic Tank [5peclfy Requirements] L,��-4---- ------- ---- -= ------------ , Disposal Field (SpecifylRequirements]__ .-. _ (� ; ____r_ ----------------------------- _ _ _____ ______ _ ______ ` ------------------__----- , may + (Draw existing and required addition bn:Peverse side] I hereby certify thaT 1 have prepared this application and that the work will-bedone in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Loca'I"Wealth District. Home owner or licensed agents i signature certifies the following: 11 "I certify that in`•the performance of the.work for which this permit is issued, I shall not employ any person in such manner asto become Signed-.-- ---Own �' it to Workman's Compensation laws of California." ffff/ er �--BY{ - -I "SC , --- - Title------------------'------------- ------------------ --------- - -- (If other tha}'owrter] OR EPARTMENT USE ONLY APPLICATION wIv ACLI=PTSD BY---------- = .?g— � _ I iE ------------------------------------------- ---------------- --DATE. ------- DIVISION OF LAND NUMBER------------ _ - ------- - ---- -- ---- ------------------- -- DATE ADDITIONAL CO J�MENTS------------ -- # t ----------- ------------ --------- ----------•------- '=----- --- ------------------ ------- ---------- -------i�----- -- bs. ` ~ :,Final Inspection ;Y .._ ?EH 13 24 O - ----------------- ------- - ------ ----- -------- ---Date S - - LOCAL HEALTH DISTRICT F8s 21677 REV. 7176 3M