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Vol „f FOR OFFICE USE: \ FOR OFFICE USE: \APPLICATION FOR SANITATION PERMIT ---- - Permit No._______.__ (Complete in Triplicate) --------------------------------------------------------- d ' � -------------------------------------- ------------------ This Permit Expires 1 Year From Date IssuedDate Issue _----------------- _ 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 compliancewithCounty Ordinance No. 549 and existing Rules and Regul`ati ns: / JOB ADDRESS/LOCATION - 4- -°(-f—ftt.f.s4 ---------- -- CEN L4�.C¢,Q �CEN TRA T - Owner's Name ! - Phone Address - ---------------................ ............ -`0` A91( - - - - City - ZiP 9. z --- ------ --- d Contractor's Name______________________rin,34A-411�__ _ -------------License #_- '3 _Phone__ ! --9607 Installation will serve: Residence� Apartment House.❑ Commercial ❑ Trailer Court E]otel ❑ Other---- ---------------------------------------- Number -- ----Number of living units:------(/--------Number of bedrooms-_-_- __Garbage Grinder------------Lot Size----- (___x-Z yJ---.-._-_-___-_- Water Supply: Public System and name-------------------------------------------------------- ---------- --------------------------------- ----------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe?� Fill Material.-----------If yes, type-------------------------------- (Plot _____..__.__---- -.(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,) `1 �r PACKAGE TREATMENT [ ) SEPTIC TANK Si e-__--_S__.____? __5�_________________________________Liquid Depth-__- _____-___-____-___--- Capacity_/6.0-0__-___Type_-_4 _Material__ _t__No. Compartments_-_ __.�________..__-- Distance to nearest: Well------- -------------.-------Foundation----/0---------------Prop. Line- --------------------------- LEACHING ine__ __ ._.________--LEACHING LINE No. of Lines-------3---------------- Length of each line-------- ---------------Total Length..--1Z,_Q____---------------------- 'D' Box---_v-_-Type Filter Material-_R01:upp__---Depth Filter Material-----/C?--------------------------------------------------- Distance to __________________________________________________Distanceto nearest: Well-----/--0 1`"-__.____Foundation-_-____� r'--------Property Line------ --------------------- r SEEPAGE PIT rA Depth---I -_-__Diameter_ ,�__`f.� ____.Number----------1------------------- Rock Filled Yes D� No ❑ -- �� x t Water Table Depth---------------------------------------------------------Rock Size-- -!- -- 1/y � . r Distance to nearest: Well_;____1 SQ_-_')'"_______________.Foundation____,r(2__-- ____-.Prop. Line-__. _ _________-.-. REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date._---_-_--_____.__.-___-___-___---_--.._---_-_) SepticTank (Specify Requirements)------------------------------------------------------------------------------ ------------------------------------------------------------ --------- Disposal Field (Specify Requirements):----- --------- ------------------ ----•-------'--- -------------••--•--------- ----------------------------------------------------- ------------------ ------ -------------------- ------------------------------------------------ -------------—----------- ------ ----- (Draw existingand 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 Compensation laws of California." Signed---- Owner c ---------------------------------------------- BY------------- --G- - - -- Title --------------------------------------------------------- - (Iam f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -- --- ---------------------------------------------------DATE. -,� ------------- DIVISION OF LAND NUMBER----------- ----- 7---------------- -------------- DATE------------------------------------------------ ADDITIONALCOMMENTS------------------------------------------------------------------ -------------------------------------------------------------------------------------------------- ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ -------------------------------------- f- s Final Inspection b , ---------- - Date EH 13 24 / SANJOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7r76 3M