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FOR OFFICE USE: f-OR 0ftiCt Ubt: A .. APPLICATION FOR SANITATION PERMIT .. � (Complete in Triplicate)' Permit -- ------- ------- �7 ' ............................ ..................... Date Issue ------..... This Permit Eicpires 1 Year From Date Issued y f Application is hereby made to.the SaniJooquin Local Health District-far'a permit'to construct and'iristdlf the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules-and Regulations: '^ I JOB _ ADDRESS/LOCATfON�-..._ ,1 ._.. _----.CENSUS TRACT...................... �� \3 -Owner's Name....... Phone (� -- --......_.... . . ....... .........'-----------'--'--'------'--- ------' ------------------------------------ Address -------- --------- -------- Address--------- - .... 5- -- Cit Contractor's Name......... .-- j---- i . .. ..................... . .. .....License #3 13 / .. ' Phone.14)J. ( L 7 Installation will se-rve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ N Motel Other ---- ---------------------- ---- Number of living units:.......----- _- Number of ..o-._.. g bedrooms.---_.......Garbage Grinder:_:"_ Lot Size_-��„C-� ------.............. Water Supply: Public 5 s#em and name__....- .--- �� - e PP y` Y Private G" Character of soil to a depth of 3 feet: . Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ ',Clay Loam ❑ Hardpan Adobe ❑ Fill Materialyes, 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,l PACKAGE TREATMENT [ ) SEPTIC TANK ..- ..............Liquid Depth.._-:--.---------'-....... [ 1 Size............. .'------"------------ Ca acit „7lM. .. �. . P Y ----.fyp, ' "'Material:T T No. Compartments. Distance to nearest: Well--------------------- - ------- Foundation_-------- Prop. Line.-- LEACHING LINE [ ] No.,of Lines _ .......... ...Length of each line......................._...... Total Length .. 'DBox---.......!Type Filter Material........ .......... Depth Filter Materia!-.'--...._:....----...----...--------'-.- ------------.-------" Dista"rtce to nearest: Well------------- "-' --- Foundation------------------- - -Property Line.-------------- --------- ---- SEEPAGE PIT [ S Depth...:- '- . _ �..Diameter---------------_...Number-.-'---------.--------------- -. Rock Filled Yes ❑ No ❑ Water Table Depth--------------- ----------- - - -- -- -- ---- --.Rock Size---................ ...... --------------' Distance`to nearest: Well--------------- -----'...............------Foundation_.....___...._ ......Prop. Line...................... REPAIR/ADDITION (Prev. Sanitation Permit#---- .--..---' .---- ---------Date--- --------- - ----- -----1 S6pfic Tank {Specify Requ•irememsl...- --� ' " " ' .................. Disposal Field (Specify Requirements) - = �. /-.:_.r✓ -. . ----------------- ------------- --- --- - ---- ---- ----------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 toWorkman's pensation lows of California." Signed- - �: ... .. . ....................Owner 7ft By----------------- " ' . _Title......... ---- -- ilf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --..: " ......DATE ...3- -? ... ' DIVISION OF LAND NUMBER.C.,----......:. DATE.................... -'-- ..-- ------ ---- ADDITIONAL COMMENTS.................... ..... . -------------------------- --------------- ------------- ---------- " ---------- __ h - Final Inspecslon b .. y:.... U k�..-.... -------------- -----...:..................................Dot " ------"- --- --...... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV.'776 inn