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FOR OFFICE USE: FOR OFFICE USE: oAPPLICATION FOR SANITATION PERMIT 76 �� - - ------ - - --- ---- \ � (Complete in Triplicate) Permit No._ ___- _"__ ________ ----- ---- - -- --- '- -- � Date Issued--// o�� ----------_---------------------------------.------------ This Permit Expires I.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 comlance with County Ord' ante No. 549 and xisting Rules and Regulations: c JOB ADDRESS/LOCATION_ CENSUSTRA TRACT-------------------------------- ------------- l Owner's Name -/_00s t - Phone , ��- _. ------Zi Address---------- -- ---- rr- ------- ------- -- - - - - ------ - CitY- - - -- -- ----------- P--------------------- / Contractor's Name _/� '`� � License #_ 1. - Phone -f - ------ `G Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ _ Motel-FlOther------------------------------------------------ ------------------------------ ----- ---=- r Number of living units:__._/--.__.Number of bedrooms----r�__Garbage Grinder-____-____Lot_Size__(F_DXX-2_Q-------------------------------- _ Water Supply: Public System and name-------------------------- ---------------------------------------------------------------------------------------Private OK Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adokke�r 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 [ ] Size-----------------________ ----------------------------------Liquid Depth_________________-____� Capacity--------------------Type.----------------------Material--------------------------No. Compartments_. ...� Distance to nearest: Well---------------_-------------------.-------Foundation-------.------------------Prop. Line____.___----_--__--- LEACHING LINE [ ] No. of Lines.__.-----_------------------Length of each line-------------------------------Total Length.________---____--_--____-_-__-___ 'D' Box------------Type Filter Material--------------------Depth Filter Material------------------------------------------------_----------_- V) Distance to nearest: Well----------------------------Foundation-----------------------------Property Line__________-____-____-______--.-_-- SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number--------------------------------- Rock Filled Yes ❑ No ❑�.� WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance to nearest: Well-------------------------------------------Foundation---------------------------Prop. Line__________-______-_------ REPAIR/ADDITION (Prev. Sanitation Permit#-. __-__________-___________-Date---------------------------------------------- _/ ____________________________--___________) Septic Tank {Specify Requirements) P ------------------------- - ----------- --------- ;6 Disposal Field(Specify Requirements)-_____ _ ____ _._ - ----------- ---------- ---------- --- ------ --------- ---------- ----------- - - - - - - - - - - - - ------------- -- - o"Z - ------,------------------------------------------ -------------------------------------------------- ------------------------ �_ Od exist1fig and required addition on reverse side) I 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 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--------- ---------------- -------------------------------------------- ---------Owner By------ ----------------------------------------------------------------------------------------------Title-------------- --------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - --------------------------------------------------------------DATE. --------------------- DIVISION OF LAND NUMBER--------------------------- -------------------------------------------------•------- DATE------------------------------------------------ ADDITIONALCOMMENTS--------------------------------------------------------------------------------------------- ---------- ------------------- -------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- ---------------------------- -------------------------------- ------------------------------------ -------------------------- ---------------------------------------- -------------------------------- - f Final Inspection by:----- --- ! -- ------------------ ------------------- ----------- ------------------------ -------Date_J.__-f_ __---7e--------------------- EH --------- ------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7176 3M