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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- --- (Complete in Triplicate) Permit No----� 6 ------------------- ----- ------------------------- Date Issued-K4-6412 � _- '? _______________________ 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 Ordinance No. 549 andexistingRules and Regulations: ��, JOB ADDRESS/LOCATION-------`f-(b./------ ?rs __.._ p /► -_----------------- ---CENSUS TRACT-1--- : Owner's Name---IA-m— -4 ------ �------ $.. ----- ----- --- - ---------------------- --- --------Phone� —SyDV----- --------------- Address---- 7� - -------CitY---7C , /U ZiP -S Contractor's Name-. fs �t!�S`/'Yi?/tJ License 7'f' 2 Phone_-J S1 7.5— Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------------------------- Number -------- ---- -- - - --------- Number of living-units:------/_______Number of bedrooms __ Garbage Grinder----I------Lot-Size- 3/¢___-------- ----------------------------- ---Nater Supply: Public System and name--- _,Ful-- ---------------------------- ------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand D-- Stlt�Iay E]---Peat❑- SandytoamX C-Tuy-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,) 15 /o r PACKAGE TREATMENT [ ] SEPTIC TANK [ti]� Size-___- ___ ___ Liquid Depth_--..-.-�------------d_ t --- ------- ------ lt:Capacity/ f��__tEJ�KFype-_f1��T�Q,( ial___(4_AA t1f No. Compartments__-----�--_.---,__________--J Distance to nearest: Well________APO-----/—'i---------Foundation___.�1�.---A—_�-Prop. Line.----- — LEACHING LINE [,40" No. of Lines---.______ -.--.Length of each line______ __rr___.Total Length _.__--_- 710-------:____ . _ _ 'D' Box___ --__--Type Filter Material-JE __Depth Filter M terial-_-�Z-_11.1- Distance to nearest: Well_____l_/ArAF__"_.Foundation_____1 ------ 'F,_Property Line--.- _�"' r�____. SEEPAGE PIT L#r Depth- .�_P&ameter---33_ -----Number----.. --------------------- Rock Filled Yes R?O'"No❑ Water Table Depth---------------------------------------------------------Rock Size____ Distance to nearest: Well______�_Q___F --------------Foundation-—5-9__r7`Prop. Line__Z>�__ REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date-------------------------------- _____-_-Septic Tank (Specify Requirements)--------------------- -.---------------------------------------------------------------------------------------------------------- -------- DisposalField(Specify Requirements)---- -------------- ------------- -------------------------------------------------------------------------------------------------------------- ------------------------------------------------ ------------- ---- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this applicatioif 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 performartce of the work for'which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation I ws of- California." Iligned --- ----------------- ------------------------------------Owner BY - -- - - Title C --------- - ---- -- -------------------------------- (If other than owner) it FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ___ _ ___ _ ___.._._ DATE_ __ -.. DIVISION OF LAND NUMBER __- ______ -__ DATE__ --------------` ADDITIONAL COMMENTS-------------------------------- -r ^-----------�---- -------------- ------------------------------------------- -------- -- ---- - -- ---------- ---- -- ---- - � Final Inspection by r Date EH 13 2A SAN JOA IN LOCAL HE LTH DISTRICT Fos 21677 REv. 717�61M