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FOR OFFICE USE: --� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) it o 2k.�./W_...... .. :. © •------• ---- •--- ( � � NN a kssued.tJ.�� .-7.8 c •• .................. 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 549 nd existing'Rules and Regulations: ' JOB ADDRESS/LOCATION..--. �4n- - . . - . ............CENSUS TRACT. 7 Owner's Name. -------------- ---- - ------ ------Phone........------------------------.... Address...-----;d d ,/ -----.Cit Zi Contractor's Name__. `--- -- -- ....................License # . !..._Phone Installation will serve: Residence Apartment.House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- . ......... y ` Number of living units:...-.I--------_ , er Number of-bedrooms...: ._. Garbage Grind ...---------Lot-Size----.(r. ./�.� .. I Water Supply: Public System and name. . ---_... ------ --- '---•----•---- ........_-----------------•------.Private El Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay 0 Peat ❑ Sandy Loam ❑ Clay Loom ° 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.] 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if p btic ssewer.is"available within 200 feet,] 4 PACKAGE TREATMENT [ ] SEPTIC TANK [ ) Size -- .-:l,-.� --....'-------------------Liquid Depth...:.------------------- #Capacity-1A.0D---Type... Material..-- : No. Compartments.-----/ ------------- r Distance to nearest: Well----- � rProp. Line. . .........Fo ndation... D ............. A # LEACHING LINE j ] 'No. of Lines ... ...................Length of each lino... _�5 -. Total Length ��._.--- -.- ow C. D' Box-".--.:.....Type-Filter Material.... ... Y Qepth . ..-Filter Material,... ------------------------------ ---------- I - Distanceto nearest: Well...........- „- .. ..Foundation------------------ ----=---- Property Line....--.-..._..._. SEEPAGE PIT [ ] Qepth _ . .Diameter..��. ........Number...... -1------..._..._---- Rock Filled Yes ' No Water Table Depth ----------•---:-- Rack Size.--.1.: Wil K-------------- Distance to nearest: Well---- -._.------ ..Q.....Foundation------------ ..... ......Prop. Line... �" ..... ---- Date----------------- -------- ------------ ) REPAIR/ADDITION (Prev. Sanitation Permit#...........:.......... ... _ _ 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 tw111-e done in accordance with San Joaquin County Ordinances, State Laws, and Rules :and, Regul.6tions 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' fCthall not employ any person in such manner as to become subject to Workman's Compensation-laws of California." Signed--- Owner By..-.... �.: Title--------------------------- ....-- -- ----- ------.- i (if other than own ] POR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.......... . .. DATE ..:me _71g DIVISION OF LAND NUMBER._. ......... ...... DATE. ------_ - ------- ADDITIONAL COMM ENTS._"..�yr��0. A__ C.. ------------------- .................. ......... ...... ---- - - -------- -- - --------- ...----- �--p� .�. ---------------- Final Inspecf,on by --------- Date....,3- 7�7� Eli 13 saSAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21477 REV. T/7e 3M 1