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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------ -- (Complete in Triplicate) Permit No-x _"_ __ -_ 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 Count Ordinance No. 549 and existing Rules and Regulations: , 29.7 ADDRESS/LOCATION ----- ------- Owner's Name___________-___---- ------------------------------ - --------------CENSUS TRACT------------- honeL � - P ----�---- --�---�--- ----- Address---------------------------- - ( (. dl w -- - --•---City- - --------Zip------- --- ------------ Contractor's ----- ---Contractor's Name_____.___ -------------------------------License ----Phone__ Installation will serve: Residence," Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------- ------------------------- Number ---------------- -----Number of living units:- Number of bedroom s- Grinder----.-------Lot Size___!__ ______________ Water Supply: Public System and name----------------------------------------- ----- ------------------------------------------------------------------- Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 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 seepage pit permitted if public sewer is available within 200 feet,) aq PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth--------------------------- Capacity---------------------Type-----------------------Material----------------- --------No. Compartments----------------------------------1 Distance to nearest: Well_._..._.______-----------------_______Foundation__---__-_.______.__..-_Prop. Line-------._________.___.-__-- LEACHING LINE [ ] No. of Lines-.---.---------------------- of each line-------------------------------Total Length---------------------------------------- 'D' _ ____________--___.___________._'D' Box------------Type Filter Material--------------------Depth Filter Material------------ _-.---.- .-_.__-------- Distance to nearest: Well----------------------------Foundation____.____._.____________Property Line___________________________._---- SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑ ` WaterTable Depth---------------------------------------------------------Rock Size--------------------------------------------- Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line_______-___-______________ REPAIR/ADDITION (Prev. Sanitation Permit#-------------------- ------------------------------Date----..__..._..____.-________-______________) Septic Tank (Specify Requirements)------- = ------ Disposal.Field (Specify Require nts).._. '� .. � w ---------------- > ------94 --------------------------------------------------- -- -----------------------_---------------------------------------------------- (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 beco jest to an's Cpmpensation laws of California." Signed T ----- - T Owner 04,Z,4 By-------- --- - - - ------ ---- --Title---------------- (If other than own FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY__ _ _ _ _________ -------- ------------------------------------------------------------------------------------------- -------DATE..----*-L---7_ --------------------- DIVISION OF LAND NUMBER----- ----------------- ---- -- -- - --------- -----------------DATE ----------------------------------- ADDI IO AL COMMENTS__ _2-- _.1� - 6�G of _ --d ------------- - ��,,, ------------------------------------------------------------------------------------ ------------------------------ - - -------- - FinalInspection by:------------ ---------------------------------------------------------------------------------------------------Date---- - ---------- EH 11 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M