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} FOR OFFICE USE: 6 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No._-_ =..�7 Date Issued................ i •-••••........--- i/. .. .. ................. This Permit Expires I Year From Date Issued Application is hereby made to.the San Joaquin Local Health District for� permit ,to construct and.install the work herein described. This application is made incompliance with County-iOrdinance No. 549'and existing�Rules and Regulations: y i JOB ADDRESS/LOCATION_..._..-- �1.. , - ............... ...-------------------.CENSUS TRACT..............-.--.- Owner's Name '. - --------- ................... ........ ..Phone---............... y1t'�s Address..`r3-f.... ._. �. J.... `r00'. ...- City ---------------------- Contractor's - ---------------Contractor's Name -- License Phone..®; � ....... . .................................. Installation will serve: Residence ❑ Apartment House [] Commercial 0 Trailer Court ❑ ' Motel ❑ Other----- --------- j-------------------- �/ g -- Il•� g -----....Lot Size-------7,4- ..- l ------•--- - .. .. Number of living units Number of bedrooFns..... Garbage Grinder-.. Water Supply: Public System and name- � .� . .................. -------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ SiIt.❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe [] Fill Material.. .... ....If yes, type--------------------- i {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,] PACKAGE TREATMENT SEPT] � ....._.... 1 ¢ -- ----- Liquid Depth.--- ....-- - -----C TANK SizeX Ca acitY �T,670-----TYP.e. �.....-- -. Material.-. - No. Compartments_ �-------------- - Distance to nearest: Well......... F° ......Foundation_-.-/e- --------- . Prop. Line...'.o� ..................C!i LEACHING LINE [ ] No. of Lines ...... ----------- "�' f �y�--------------- Length of each line....-- ..---------------- Total Length _ /-:--- 'D' Box............Type Filter Materia!- Atr Depth Filter Material--.---. --- ----------- ----------------------- I Distance to nearest: Well------------:g----- :.._.Foundation.....-....-- Property Line---------------------- ... SEEPAGE PIT [ ] Depth.-..VA.. . _Diameter..... .........Number....__... _.._.--------------- Rock Filled Yes No❑ Water Table Depth..................--------------.----------------------...Rock Size.-.- ------- ------------------ i Distance to nearest:.Well--- ---------------------------------------Foundation.................... Prop. Line..---.-------......... REPAIR/ADDITION (Prev. Sanitation Permit#---------------- - Date---------....____,__......-_---_._..__--- Septic Tank (Specify Requirements) , -- ..... Disposal Field (Specify Requirements).................. ..... ......... .......... --------------- ---- --------- - ---- ---------------- - ---- -----------1 - ------ --- ---------------------------------------------............... -- - ----------------------- - --------....- I (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 become subject to Workman's Compensation lows of'California." Signed -- - ---- -- - Owner BY Title .-- --- --- - -- ---- - --- (tf of er than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. DATE -.---.. ��-��. ............... DIVISION OF LAND NUMBE .--- ...DATE------.................... ADDITIONAL COMMENTS....------. .. .............. ..... . ............. ..... -- -- �e . y Final Inspection b .Date:.-- -- -------- -- E-H 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M