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FOR OFFICE USE: - ✓ FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT 4--------- ------------------------ _4 (Coinplete in,Triplicate) _ , r Permit No---,.-.,n-------------- --------------- ----------------------------------------- Date Issued-.�.� C_ _�� ` ------------------------------------------ ------ 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/LOCATI , _.__ CX9,5- _ -- - . -- ----- ----------CENSUS TRACT----------- ---- ``// Owner's Name -- --- - - � one.7. rg_;P r Address 17'�a------- ---------------- - ------City ---- ---zip------- ------ ,�yy ------- Contractor's Name-------- -------- -- -- --- - ---------= ------------- �� License #__ is-'3 Phone `�-�' -----------_. I Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [G� qq Motel ❑ Otlier=............. Number of living units:-----L_-------Number of bedrooms------------Garbage Grinder_-_.__..___Lot Size__? �)e- Water Supply: Public System_an-a name -- ----------------------------------------- -=-- >, :'• Private ®� 3 Character of soil to a depth of 3 feet: Sand ❑ S;lt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ ` Hardpan ❑ Adobe LZFill 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 [ l Size------------------------------------------------------------Liquid Depth----------- - 91 Capacity_ TYPe' ---7r_-Material--------------------------No. Compartments•-- ----------------- W ------------- [ ] Na. of Lines--- ------:--"-------,----Leri th'of each 1 Foundation--------------------------Prop. Line------------------------------ + istance to nearest: Well_____________________•_ LEACHING LINE g line--. ` Total Length. CA4 f 'D' Box_---.-------Type Filter Material--------------------Depth Filter Material___________________ 1 Distance to nearest: Well-.-: ' ;----.Foundation__.___ _____________Property SEEPAGE PIT [ j Depth----- ------Diameter--------------------Number-------------------------------- Rock Filled Yes No ❑C t Water Table Depth---------- -- ------------------------- RockwSize---- ---------=---------------------------------- x,. Distance to nearest: Well------ - -------------------------------Foundation---- -------------------.Prop. Line----- ------------ REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date-------------.-------------------------- } R i Septic Tank (Specify Requirements) ----`- ----- ---. -- '' — --w '-------- ---- ----------- ---------- Disposal Field (Specify Requirements)----- ----- � .� - ------- -------------------------- ------------------ ----- =l-------�----------- { ---------------------------------------------------------- (Draw existing and required addition, on reverse side) hereby certify that I have prepared this application and that the work`will be done in accordance with San Joaquin County l Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home Towner or licensed agents signature certifies the following: -1 .1 - .y } "I certify that in the performance of the work for which this permit is issued, I shall not employ any.F erson in such manner as f4 to becom su ct to Wo an's C pensation laws of California." i Signed----- -- ' --------Owner .�'..11 �" BY------ ------------ ----------------- ---;•� '�1�' `�`� -- -- --Title------ ---- - - --------- (If other than owner) �l / O EPARTMENT USOONLY APPLICATION ACCEPTED BY_____._ --------------- ---- DATE. 6 DIVISION OF LAND NUMBER---- ---------- ------------ -------------------------------- DATE ADDITIONALCOMMENTS --- ------------------------------------------------------------------- ------------- ----------------------------- ------------------------- ------ ----------------- ----------- ----I------------------ -------------------------- -------------------------- --------------------------------- - f __ ....... i - ------- - - ----- Final ---Final Inspection by \ ------ - ------------ ---Date-------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M