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FOR OFFICE USE: _ FOR OFFICE USE: Y APPLICATION FOR SANITATION PERMIT r� --- - ------------------------- 11 1 (Complete in Triplicate) Permit No--.- -------- ------ f Date Issued-- ------------ ---- --- -------------------------- 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION... ---d. -- -f_.____44!r------ __._wZ-C9-------______ ______.CENSUS TRACT------- -------------------------- Owner's ----- -----------.-------- .._.Owner's Name-----U N12r�/0- V//VT/v�/4_.p. e ---------------------------------------------Phone S - Address-- D------3p-x------- -6----------------------------------------- - -----------City_4�.C,_.s?f o4Y-.�-!------- Zip---` s3 o-------- Contractor's Name-_--__V_ 1 14_N._._. _ A� _ - License #..;2-&--, o,,S----Phone....5-17'_�_�`_ Installation will serve: 1 ; Residence [;go Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------ ------ Number of living units:__;_____ ------Number of bedrooms.------ .-._Garbage Grinder--------.----Lot Size---------_-------------------------------------------------. Water Supply: Public System and name-----=--------------------- ------- -- ------:-----------------;r _-:----- .---------- ---_ . _ _. _ _ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam [E�o Clay Loam ❑ I 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 �'] SizeGG------------------------Liquid Depth.___"'_ ---------------� O� a Capacity-16 00 -.--Type.- :'--------=--------Material 4?-A7G `__No. Compartments--:------=- -_______.__--____-- Distance to nearest: Well----- 3 o-,,OT----------------Foundation-------.------------------Prop. Line-,=------------ --- LEACHING LINE' Nor of Lines--------- Length of each . line.-.---�� h, _ /Xo _ __________________ oaeng _ _ 'D' Box--'------ Y -.Type Filter Material--------------------Depth Filter Material-------------------.-------------------------------------- ---. Distance to nearest: Well----------------------------Foundation----------------------------.Property Line--:------------- ------_-----------. - SEEP PIT [ Depth_._._..._._._.Diameter :_.__.---------_---Number---____--�=__--.-_-.-------. Rock Filled Yes ❑ No 1 1 t Wafter Table Depth-- Jz / ��- -----=- -------Rock Size:---- A/1//X /1 X /o - Distance to nearest: Well--------- --- --- -- :------ ___--Foundation--:------:---------_-_---.Prop. Line-------------- Q ] REPAIR/ADDITION (Prev. Sanitation Permit#------- ---------------------``-- Date------------------------------------.-----_--_-} ; I Septic Tank (Specify Requirements[- - _----- :-=-------= -------------------------- ----- t-=----=---f --- Disposal Field (Specify Requirements):_ _._ .____�7.�..�__�!_�--.....7L_ � ___ ��Z X��_. ----------------------------------------------------------------------------------------------------------------------------------------------=----------- -- ----- ----------- -------- - - - - -- ----- ------------------ --------------------------------- --- ---- --------- _ -------------- -------- ------ --------------------- (Draw existing and required addition on reverse side) I hereby.certify that:l 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: '. "1 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 laws of California."._ Signed------ -�- -�,r�.�'zr-*��------------------`------.�------ - ---- 0`^mer __. xBy .- - _.-Title --------------------------------- --------- (If other*than owner) ' OR DEPARTMENT USE ONLY + ; APPLICATION ACCEPTED BY-=----- - �/ - ------ ------------------------DATE.-- -� ZZ --------------------- DIVISION " gD1V1SlON OF LAND NUMBER ---------------'--- -- --------- -------- - ---------- DATE------------------------------------- ----------- ADDITIONAL COMMENTS-' - ---- ------= ------------------------------------------ ------------------ ------------------------ ---------------------------- -- -------- ------ ------`------ -- ----4-----------------------= -------------=--- --------- ---------------------- ---- -- ------------ --- Final :Inspection by:------ --------- ------ --- -- ---- ------------- -------------------------------------- --'----_Date.-: ? --------- EH 13 24. SAN JO UIN LOCM-HEALTH DISTRICT F&s 21677 REV. 7176 3M