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i FOR OFFICE USE: - FOR UFF[CE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit / 'Date Issued �� ••----- -------------- ---- ---------------- This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin Local Health-Distr4ct'for-a permit to construct and install the work herein described. € This application.is made in compliance with County Ordinance No. 549 and existing Rules and Regulations; JOB ADDRESS/LOCATION--- �J - cJ "CE SUS TRACT.._ Owner's Name_'.. „ t/,�...... ......-- - I Phone Address-.--')./ City---------------------------------- -----------Zip.................... ...... f Contractor's Name .. ._'. ...... . ........................License #-5.07 .77.._Phone_. Installation will serve: Residence ❑ Apartment House []`'Commercial ❑ Trailer Court ❑ Motel ❑ Other . .. ........... Number of living units:.......1:-------Number of bedrooms_.... ..Garbage Grinder---.--------Lot Size._.. ... X.RG9e.................. .. Water Supply: Public System and name------ --------C_r.1^1,-5----. -. - _------------------------ Private Character of soil to a depth of 3 feet: Sand ❑ 5il n Clay ❑. Peat ❑. Sandy Loam 0 . Clay Loam ❑ ` ,.. Hardpan ❑ • Adobe Fill Material.- --.. ....If yes,type--------------------------- Mot --..{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 flank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK ( ] Size , --------- ............Liquid Depth.............. Capacity_.. .... ------- Type ---.......Material --.---..----..............No. Compartments..------.. ' «. -'"""Distance #o nearest: Well... --------- --- -......Foundation__. ..... ...Prop. Line.._........... s LEACHING LI-NE_: No. of Lines i ........ ............. of each line......---------- ---.-----------Total Length .. .--•-- ---...----•-_ �� - ---- --�•- 'D' Box---=........Type Filter Material........ ._--------Depth Filter Material._.:.......--....---..-------------------..-------------------- Distance; ---- .----.,-----.Distance to nearest: Well------------------ _ Foundation------------••----- ---- -Property Line....---- i SEEPAGE PIT ( ] Depth.._.:._ ---.Diameter.....................Number_ .-.- °------------ Rock Filled Yes ❑ No ❑ Water Table Depth.-- _- - �. .�__ Rock Size:.... -------------- Distance to nearest; Well._:------ ...........Foundation..'...... Prop, Line......r...,.......-,........ REPAIR/ADDITION (Prev. Sanitation Permit#...._................... .....:Date................-...--.- -._...---- 1 Septic Tank (Specify Requirements)----- -------------- ----------------------------------------- ------ -------- ------------------ Disposal -Field {Specif Requirements) ” ... _-- ---- r . . r. -'a Q .-i`.- ...... ------ -------- ----- ------------ --------- (Draw existin n and re uired additi 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, StateLaws, 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 to Work man's„'Compensation laws of California." Signed By--- - � __.. � .Owner :... - t .... ----------------- l fother.tTran owner) Title:..........t FOR DEP RTMENT USE'ONLY '`- APPLICATION ACCEPTED BY..... Y — - ....-DATE 3. I DIVISION OF LAND NUMBER------:.`..._.. ............ ........ ........DATE------ ---------------- - ....... ADDITIONAL COMMENTS-- ---------- - .........- --:....------.. .............. - . . pp i. .. - .. -wa Final Inspection by:......- _�lY .. ...... --.......:...... .............Date....... '0�3-1. .-.... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M