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FOR OFFICE USE: FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT --------------- ----- - Permit No._-�-�1_3ia (Complete in Triplicate) """--""""""""""""- -1- � Date Issued___?- ______________------------------------------- --------- _ 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 and existing Rules and Regulations: JOB ADDRESS/L CATION---I�3 """9---- /v� - - - CENSUS TRACT - Owner's Name -------------------------- --------------------------------.Phone.- �-1r_'e7-r54- Address-------- - city-------------------- --------------------------ZiP----------- ----------------- Contractor's Name--- }�e-__ � __ __-____________License #-J�57 �__-_Phone--9415; 3___. --- -- -------- Installation will serve: Residence Rq-- Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------ ------------------- ----- Number of living units:----------------Number of bedrooms---23----Garbage Grinder------------Lot Size__=:5l_�/6Zc----'_______.____"___. Water Supply: Public System and name----- ------------ --------------------------------------------------------------- -------------------------------Private oP-- Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam*�J Hardpan ❑ Adobe ❑ Fill Material_-------_If yes,type------------ ----------------- . D (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) y1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ^� PACKAGE TREATMENT [ ) SEPTIC TANK [/�]� Size--- ize=_- j Liquid Depth---57� ---------- Capacity/w/00---------Type__R";0_t-------Material-6 ---------Capacity///00---------Type-_R";0__-------Material-6 ---------------No. Compartments-----�-----------__.----------- . , Distance to nearest: Well---/®Qi--------------------------Foundation----/S__ -----------Prop. Line____%u ---------- LEACHING LINE [,&I' No. of Lines---.2------------------- Length �� g Len th of each line.___ _._ ____________________Total Length ____IS-____________.______.__._ a 'D' Box-/ Type Filter Material_44__44_ A/44—Depth Filter Material-----.2_/a ------------------------------------------- Distance to nearest:Well__ �_________Foundation__ Q_�________.Property Line___ -_� SEEPAGE PIT [4- Depth_QS_ ....Diameter..-3 `_�_ .__ldUmber______ _____ ______________ Rock Filled Yes No❑ Water Table Depth----------",Oe:)O /-------------------------------Rock Size-----�-� /f ------------------ e2^---------- i Distance to nearest: Well____110 ______________;_______Foundation____ V_______.Prop- Line__4�_lp____________- REPAIR/ADDITION (Prev. Sanitation Permit# -------------------------------------Date---------------------------------------------- Septic ___ __-_ _-_-____Septic Tank (Specify Requirements)-------------------------- ------------------- --------=---------------------------------------------------------------------------- Disposal Field(Specify Requirements)_____________________ ___________________ -------------- ---- (Draw 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: "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 Wo man's Compensation laws of California." Signed-------- -- ------ ----- - --- -- ----------------------------------------------------Owner BY-------- �1 --------------------------------------------------------------Title-----1415& �- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- -----------------------------------------------DATE ----- ------- DIVISION OF LAND NUMBER_-------- ------------------------ --------------- --------------------------------------------DATE------------------------------ -------------- ----------------DATE----------------------------- --------- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------- ---------------- ---- --------------------- ------------------------------------------------------------------------------------------•---------------------------------------------------------------------- ------------------- ---- ----------------------------------------------------------- ------qAN' ------------------------------------------------------------------------------------------------------------------------------ -------------------------------- --�-- ------- ---- Final Inspection b P by:-------- -------- - ---- Date- EH 13 24 AQ fN LOCAL HEALTH DISTRICT F3s 21677REV. 7176 3m