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FOR OFFICE USE: FOR OFFICE USE: + ! APPLICATION FOR SANITATION PERMIT ----- -------- --�---;� '•---- -------- - - Permit No.-- -�� F (Corpplete i0l Triplicate) Pe ' x _ This Permit Expires 1 Year From Date Issued 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/LO TION-_//.2 f1Z-- -- - -0 �t�i�/� /� .: _ Oy vi-- ----- - ---- -----------------------------CENSUS TRACT----------0------------------ Owner's Name 1L.1� ScSI.- ------ -�1VC-- ----- -------------------�-----------------------Phone--3.--7_--'�-1�-� - Address--- 5t�f� -------------- - ------City---c ----- '-v-----------------Zip Contractor's Name__ -_______--_�T*G__�+'Ae_��<'-__--___License #_3PS77�i�----Phone__�� &P-------- Installation will serve: Residence ❑ Apartment House Ciommercial�Trailer Court E]Motel ❑ Other --T/G --C.t..+=----------- ------ Number of living units:------------_---Number of bedrooms------------Garbage Grinder-._.--------Lot Size------------------- ------------------------____-______ Water Supply: Public System and name------------------_.--- ------------------------ ---------------------------------------------------- Private 2.-, Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam.e.— Hardpan ❑ Adobe ❑ Fill Material_------__If yes, type___-___-____________________ (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 seep ge pit permitted if public sewer is avaiElle within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ["'� Size______ /4' ------ ,CO'"f___Liquid Depth.______--07 /S� 17-1.2-11------- � ---------------- Capacity/,400-gam-'Type--- �------Material---t-�W------------No. Compartments--------4-------------------- 6-0 ----------�--------� Distance to nearest: Well-_____S _.._________ ----------- Foundation -�� Qa G / -----------Prop. Line---�----------------------- LEACHING LINE [�No. of Lines_______'-_._________.Length ofeach, line___ 00' __________.______.Total Length _--- �p--_-_---- ------------ 'D' Box-_t*v/y_Type Filter Material-✓4___//4-:Depth Filter Material_______--------------------------------------------------- Distance to nearest: Well__ r r i ______________Foundation______ Q____________Property Line____ ______________- SEEPAGE PIT �S/ 3� [�.]i�Depth_______-__._Diameter_________________Numbet_.-_____�---_____________ Rock Filled Yes @;./No❑ f�� 4 Water Table Depth 0-------' ------------- y -------------Rock Size--- `'7 1,1A- Distance to nearest: Well___ '____________________Foundation _____-_..Prop. Line____ _-__-__. REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------__----------Date-------------------------------------- _______) SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------- --------- Disposal Field (Specify Requirements) ------------------------------------------------- -- , ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) 1 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 --------------------------------------------------C>wner .;: BY -- ----------------- --------------Title---040A - ° (If other-than owner} FOR DEPARTMENT U ONLY PPLICATION ACCEPTED BY-- -------- -------- - DATE - DIVISION OF LAND NUMBER--------.___-__ _-___-____-DATE-_________________________ - ----- ------------------------------------------ ------ ----------- ADDITIONALCOMMENTS----------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- --------------------------------------------------------- - - ------------------ ----------------------------------------------------�- ---------------------- - ------------------------------------- ----------------------------------------------- --- ----------- Date:_Final Inspection by: ------ - ------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M