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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No........7 �_7 1 ---•-----•------------- This Permit Expires 1 Year From Date Issued Date Issued...�((3 • 7_-.- I Application is hereby made to-the Son Joaquin Local Health District 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/ TION.�: ��-_.. -- ---------. CENSUS TRACT..-------•-------- ---- ------ ---•- ` ... Owner's Name. .. Q , .u. —Lr _ ...--�.� ,........ ............ Pham. l--��....... 4. Address - ..._ ( a - Cit. .Zip.1..&.............. ------ Contractor's Name.. .,... . .. . ......License #� hone. *_ee--r---"-- Installation will serve: Residence Apartment Howe ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other............... - •---------- Number of living unitslr/._-----Number of bedrooms.. ...Gorbage Grinder---k�..Lot Size._�QX --Zo � Water Supply: Public System and name........---- ........ -- ••--------------- ............ ----- ---------------------------------Private Character of soil to a depth of 3 feet: - Sand ❑ Silt❑ Clay)gL, Peat ❑ Sandy Loam ❑ Cloy 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,) PACKAGE TREATMENT [ ] SEPTIC TANKSize ..... .......Liquid Depth--------------------------- [ ] Capacity... .............Type.-.--•---- .... ......Mate-rial------- ....... .........-No. Compartments--------:-------------_...... Distance to nearest: Wella.............j...............- Foundation-------- - - ------.... ..Prop. Line.................----------t LEACHING LINE ( ] No. 'of Lines .......................Length of each line........ _ _ . . Total Length ... ..............................------C . r D' Box-------.....Type Filter Material........ .......... Depth Filter Material----------------------_----------------- -----"""----- .-------K I Distance•to nearest: Well......................._..Foundation............................Property Line-------------------..__._......... i SEEPAGE PIT p El No �� [ ] Qe th................D'€ameter_..._.__--_--.......Number....---___-- ____________________ Rock Filled Yes WaterTable Depth---------------------------------------------------------Rock Size..... .... .. .---------- ....................... Distance tc nearest: Well.---.----.--_---------------------- Foundation-----.............. ......Prop. Line..--- -..------.----_..-- REPAIR/ADDITION {Prev. Sanitation Permit#----------------- - ----- -..---.-------.Date---------------.------ ...._-. -----) Septic Tank (Specify Requirements)-- --...-•---------------------- --j- ------- ------------------------------------------------------------------------- ------------ a Disposal Field(Specify.Requirements).: ----- ' N . ....................... ------------------- ----------------------- ............................ (Draw existing and required addition on reverse side) I 1 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 'n the performance of a work for which this permit is issued, I shall not employ any person in such-manner as !o become su ect to Workrr}an' mpens tion ws of Cal' ornia." Signed --- ------- --- -- Owner BY---- Title (if other an o ner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... ---------------------------------------- ---------- ............ .... DATE " � ....._.. .. ........... . DIVISION OF LAND NUMBi ------.DATE................._:. ..-- ADDITIONAL COMMENTS...... ..........._... .. ..................................... ' ." : -- ---_- -- :-------:::----------- --:::: : ------------------ ...... ... . --- - .. ---- -- Date...- Final InspecrEon b -----.. -.- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 877 REV. 717E 3M z