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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------• --.-. �� -��- - (Complete in Triplicate) Permit No...'A.._- -5. 6.3--- Date Issued..�,�(l/..7.g...._ .. ...... ........ 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 rdin ce o. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . / .. . •--------------CENSUS TRACT..---_---------- ------------- Owner's Name....................._ ------ - ------ . ------. ------ -•--------....... _-- -----. .... .-----Phone-------------------------..... ,,... Address---- ---------- ---- , S .. _ G`lI�L City p--? Contractor's Name--- --- ------ � .. . -- . --..._--------- ---- ---License #.- V�- -,�t3� . .Phone_ 4►.5 `--- Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ // Motel ❑ Other.........- .. __ .... --•---•---•-------_... Number of living units:.......(.-----Number of bedrooms__.3.....Garbage Grin er.._.__......Lot Size...�J�...., ............ - Water Supply: Public System and name_..........................C._ ..L�++I,/. ------------------ --- Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe K 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ j SEPTIC TANK [ Size.... 5X�__________________________________Liquid Depth...7..-._.___......_.__. Capacity..�.pZ.C..O-----Type.P�4t.[.. Material... fi! !'_......No. Compartments----------A'...........w_..._. R Distance to nearest: Well......77;k1^1•�_......... ---pFoundation----`Q - ....Prop. Line...,... --- LEACHING LINE [t.]�' No. of Lines.._...-..017..............Length of each Iine...GS 24�.-...._..._Total Length .. - ........._ .t D' Box............Type filter Material. -d� Depth Filter Material..-._. ......................'__ �-.-.-----... Distance to nearest: Well --....Foundation. Ot Property Line.:: �'4 ....-..... SEEPAGE PIT [44" Depth. . .......Diameter....33--___--._-Number.._.....A'__________________ �l r1 Rock Filled Yes ®' No❑ Water Table Depth.--------- ...............Rock Size....Q.)C..3_-----_ ---_-------------- � Distance to nearest: Well------- -----------------Foundation....3.v.�....-- --.Prop. Line. .. :..._... REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date__.........._..__.--------.-------------------) SepticTank (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 subj to orkm n' Cosation laws of California." Signed....... - �� " ... -•-------C>vvneSit BY-•------------------------------------------------•- , W ....Title........ (If other than owner) FO DEPAR ONLY APPLICATION ACCEPTED BY-- /`''" DATE -------•-- ----- DIVISION OF LAND NUMBER.. 7 DATE. ADDITIONALCOM ENTS................----- ---•- ----.... • -•---- --------------------- ----------------•---- -•-----• ---- -- ------ � / ........................ ..•--....__ .... ----- ----- ---- ........_.... •- ......................... -••_•.....^-•.---- .-�+-_ ... -- -- ....... r.:....-----••.._.-------•-------------•----• -- ) - Final Inspection by.. ..Date-___ '"- . .................................................................. ._- .,moi ....._......._...._. EH 13 24 S N JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/76 inn