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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Complete in Triplicate) Permit No.,7$----F#�3 Date Issued-.$-_..7/-,7,9"' ---------------"--- -- " _-." _--.___.._ 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 CountyOrdinanceNo. 55�4,I9 and existing Rules and Regulations: JOB ADDRESS/LOC ION----��Q-7 -`3--/- E'----�Y- 1!"- - ----------------------------------CENSUS TRACT--- ----------- Owner's Nan - V---- � - Ph e . (.� �'`�` � - ---------------- Address-------- ------ --...--------- - - City .. Q47�- ----L.-��---ZiP-- - - ----------- - - - Contractor's Name_ ' "-- ----- c <.4 ----f ---c l- -—----------------License #---3P_97-11-----Phone --- Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [_1 Other------------------- - - ------------------------- Number of living units:,___ f-------Number of bedrooms___,3_---Garbage 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 L�t- 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,) PACKAGE TREATMENT [ ] SEPTIC TANK [fir Size ."X-""5 � � i� ..� �.q "Liquid Depth ------- - Capacity--/_,ZD-Q------Type------ -------Material- ..""No. r Compartments------�------"-"-"---"- ----------- Distance to nearest: Well----""" ---------Foundation___-- a ---""__---Prop. Line_p�Do"_'_______-""-_ .� 6I e LEACHING LINE [L.- No. of Lines.--.-3-------------------Length of each line------q-- --------------------Total Length.--.1 zQ_----_________-------__ 'D' Box---M--__Type Filter Material_1_ P/__,L"..Depth Filter Material---------�----_------------------------------------------- r Distanceto nearest: Wel!_____ "z - ---_______Foundation__0?5—1------------Property Line--- 0"--_________----___. SEEPAGE PIT [L�- Depth-ca -r--Diameter"._.33_ -____.Number.------�------------- ------- Rock Filled Yeses- No ❑ �" _ / x/ /c Water Table Depth------- ---,-d-----------m--- � - --- ------ ----Roc)C Size - ------------------------------------------ Distance ---------------------------- - - - Distance to nearest: Well_-,.""/ v_______-"------ ----Foundation----- v� """:.""__.Prop. Line___ Q"____""___. REPAIR/ADDITION (Prev. Sanitation Permit#._" --------------- ----------------- ---_.Date---------------------------------------------- Septic ------------t__--__-_----------Septic Tank (Specify Requirements)------------------------ - ------ --------------i- ;._---------------.:----- ---------------------------------------------------"--------- Disposal Field (Specify Requirements)________________ --------*-------------------------------------------------------------------------- 4 (Draw existing and required addition on reverse•side) 1 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: r � - "I certify that in the performance of the work for which .this permit is issued,.I shall not employ any person in such an r as to become su to Wor an's Compensation laws of California." Signed---- ----- --------------- -- -- Owner BY - - - ------------- ---- ----------------------------------- - t �,. - " -""Title {lf of er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- - - DATE....... ----- ---------------------- DIVISIONOF LAND NUMBER----- -- -- ---- ---- ------------ ---- - - ----------- - --------------------------------------.DATE.---------- ------------------ - --------------- ADDITIONALCOMMENTS---------- -------------------------------------------------- -------------------- --------------- ---------- --------------------------------------- --------------------- ---------------- ------ �t- ---------------------------------------- ------ ------- --------------------------- ----------------------------------------------------- -- -- --- ------------------------------------- --------------------------------------------------- -- -------------- --------------------------- ---------------------------------------------- - - Final Inspection b -------- ---- - Date FH 13 24 SAN 4OAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M