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lop- FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.__� --- (Complete in Triplicate) --S 2 ------------------------- ------------------------ Date Issued._____ -----------------------------------------------------__ This Permit Expires 1 Year From Date Issued j 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: € CENSUS TRACT CO _- JOB ADDRESS/LOCATION -- -- --s�� -------�--"---�00�-------- ' �------- t Owner's Name.- .. - Phone_3 - 3�- Q P yP ---- -------------- ---- --------- -- City..---Address-._.. s a �' } t Contractor's Name___ _ - l c3(��'31--_3' i ---- ------- - License #--�b`��-lZ----- Phone Installation will serve3: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ }-. Motel ❑ Other.I_ , d --_a_>'4✓....`-------- Number of livin uni_Its�____ ___________Number of bedroomsQaYbage Grinder --------- _Lot Size-_.-------.:,.,_-:___-------.--------- =-- _g e Water Supply: Publcc System andi name � -------------- a`'-- ---- - --- - - Private Character of soil to a depth of 3 f et: Sand ❑ Silt❑ Clay L] Peat j�( Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ -,Fill Materja,l=-_--------- f yes, type-- -------------------••------ (Plot plan, showing si e of lot, location of system in•relation`totwells, buildings, etc. must be placed on reverse side.) 3� +,,rc; 1 % 1 i 4 NEW INSTALLATION: ,(No septic tank or seepolge :pit_permed if public sewer is available within 200 feet,] PACKAGE TREATMENT;- [ ] SEPTIC TANK s` SIZe-_._____-___._ ____ __ �� -- Liquid Depth.___ �.y___------ �r `� .Matwial_ C4 h ----No. Compartments-----4__-- --------------------- Capacity--P © € v ? I 'T I I e, 1 �tt Distance to Weare st; We 1 ---�--�`` ---_ ----_-°Foundation----�r. _t..,- Pro . Line--- ------------ P LEACHING LINE 14)�No. of,Lines______o- ._____.____.__.Length of each// lins.____ t _.__1Q_�___.Total Length..__- d_________________________� 'D' Box Type Filter Material - ��_, t 7�l�Depth Filter Material___ a_-�____ _ ______ _--- Dis anca.to riear�stt Weif `_Foundation_--- ---- -----------Property Line . _/_.-- G' ' * Rock Filled Yes No 8 SEEPAGE PIT [ ] ;` Depth_.__----'__-"Diameter--------------------Numi�er___._______-_ - -------------- ❑ ❑ { 0 Water Table Depth. = s '------------------- Rock Size t E J2_.'� ., t F Distance to nearest: Well------------------ -" --------.�` Foundation-------- ---------------Prop. Line-------- ----------------. REPAIR/ADDITION (Prev. Sanitation Permit#_-___._________.__-----'--------------- 4 x ------- -------�,- ---] t ' •_ � �I 4 Dat .---'-, ----- ----, ----------- Septic Tank (Specify Requirements)-------- --------------------- ------------------ ----------------------- - --------=------------ = = - Disposal Field [Specify Requirements]- ------ { 'x k =----------- f i I - >. ------------- = ---------------.--------------- ----- , [ (Draw existing and required addtion'on reverse side) I s I hereby certify that fi-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 Sad 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, 1 shall not employ any person in such manner as to become subject to Workman's .Compensation' laws of California." . 1_� 4 Signed---- - ------=----- ow.ner _ , --. y �- V____ By----- -------------------- -------------- --- ----- T-tie---A - {Lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BN DATE.--..__- - -----' ---------------- ---------------------------- DIVISION OF LAND NUMBER ---------- -- ---------------- --- ------DATE-------------- --- ------------ ADDITIONAL COMMENTS------------------- ----------------- ---------------------- ----- -------------------- ----- ----- -------------------------------------------------------------.-------- --------------------------------------------------------------- ------------ --------------- ------------- ---- --------- ---- - - Final Inspection by=-- - -------- - - -- x -_----- ---Date--...2 --- _ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M