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FOR OFFICE USE: r �1 FOR OFFICE USE: \\PPLICATION FOR SANITATION PERMIT '------------------- (Complete in Triplicate) Permit ------------------------------- c� q Date Issued- .............. ssued- .........__-_._"-------------__- __-__._- -- j This Permit Permit Expires 1 Year from Date Issued T Application is hereby made to the San to oa� Luid cal Health 61 15— D f a District permi to construct and install theork herein described. This application is made in cc* o liance with County O ' anc No. 549 and isting Rules nd Regul lia�c! �Iw JOB ADDRESS/LO 10 �I 5 C '� iJ CENS�S TRACT Owner's Na a----- - - -- -- --- -- -------- -- ------------Phone-------------- ---------------------- -Address--- -------city - _-Zip / Contractor's Name-------- - __ ____.---- a__--- ----- _--------------------------License # �o_ _ �_Phone___-4�-J� -� t� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ---- - ------------------------------ Number - ------ -- -------- � � � Number of living unite:-__ _--._---Number of bedrooms--__-- _-- Garbage Grinder- _Lot Size------��-__-an --------------------- Water _.----- --------- Water Supply: Public System and name ---------------------------- --- ------- -------- -------- ----- --- ----- Private [ Character of soil to a depth of 3 feet: Sand ❑ Sil Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Materiae_-_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 publip sewer is gvailable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ize_,d __ / _ / ------------ Liquid De ------ / 0 0. Compartments___ ____________ Capacity---l-�"--- -----Type-�1� -- Material--- - - --- - ----------------- ance to neare^s�t: Well__-__ _®_-��_{___________________Foundation___�_ ______._Prop. Line�r/ LEACHING LINE No. of Lines_.__.-_"'______Length of each line.-- ------------------------- 'D' Length.-_/_ _Q._j_________ D' Box__ _, _Type Filter Material._ _ �i Depth Filter Material _____� _-��---_--_ -_--___ --_____-. -_ ._-___- istan to nearest: Well_ ___�___-_----Foundation-_---_/_10_/1 _-_®_1-___-__Property Line__- l_.________________. p / I - ---------Number-- __ __Y_�-------__------ f R filled Yes SEEPAGE PIT ( De ths�b--____._Diameter_ __ ' o� l/ Water Table Depth---------1 ----------------------- ----Rock Size------ l" -------------- Distance to nearest: Well---------- __)------------------Foundation-----1_-_Q__)----------Prop. Line___.r/____-.-__-_. REPAIR/ADDITION (Prev. Sanitation Permit#___________________________________________________Date--____--__---_-_-__----__-_---____-____-____-_) Septic Tank (Specify Requirements)----------------------------- ----------- ------------------------------------------------------------- -------- Disposal Field(Specify Requirements)----------------- --- --------------- --------------------------------------------------------------------------------------- --- -. ----------- -----------------------------•----------------------------------------------------------------'--------- --------------------------------------------- ----------------------------------------- (Draw existing and required addition on reverse side) `S`- 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 l 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------------------ - - - Owner BY--------- -------------------- - - ( Title------------ ---------------------------------------------- If other than owner) FOR DEP TMI ENJ USE ONLY APPLICATION ACCEPTED BY-------- 'c - "' -------------------------------------- DATE.-------- 71131-77-------------- DIVISION OF LAND NUMBER--------------------------------- ------------------------------------------------_-----------DATE---------------.- ADDITIONALCOMMENTS--------------------------------------------------------------------------------------- -------------------------------------------------------------------------------. --------------------------------------------- --------------------- - ---- ---------------- - - ---- -------- - / ---- -- -- - -- ------- ------------------ 1`Q = call R }` -- `-�_ :�j9d- -nom- Final Inspectio by:------ - _ j Date ------ EH 13 24 21SA� JOA�IN LOCAL HEALTH DISTRICT 1 f&S 216 7 REV. 7/76 3M