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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------- ------------.------------ -- Permit No -_S! (Complete in Triplicate) ------------------------------- ---------------------- -- Date Issued-_-2"------------- ________________ 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 existi g Rules and Regulations: JOB ADDRESS/LOCATION__-- --.-- -- -�.-- -------6�"-�-- -�-- ------ - -- - --.CENSUS TRACT--------------------------------- Owner's Name.- -------- --- ------------- ----------- --------- -------- `4------------ ---- Phone-------------------------- --------------- - Address ----- ---- Address ----.----------- - - --- - -- --- ----- ---------- --------------------- - ----------=------City----- ------- ---- /rte/ ---------Zip---- --- ------- --------- ------License # .Q- 1-`/ Phone., ,- /�- Contractor's Name_----_ -- - - ---------- - -- -- -. -.- y Installation will serve: Residence ❑ Apartment use ❑ Commercial ❑ OiTrailer Court ❑ t .Motel ❑ Other r-------------------'---- '-- --------- } Number of living units-----------------Number of bedrooms.----.--=_-Garbage Grinder---------- _LotiSize--------------------------- -------------------------- Water Supply: Public System and name --------------------------- ---- '''`- u - --v -------------------- Private El- ------------- Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay-,E Pea EJ Sandy Loam ❑ Clay Loam ❑ 1 Hardpan ❑ ' Adobe ❑ Fill Material9-.--=.---..If.yes, type----------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must.be placed on reverse side.) �] . _ R - NEW septic tank dilable within 200 feet,} TAREATMENT [[]o SEPTIC TANK jseepage :pit permitted if public sewe_-Al-141 is a�1- k Liquid Depth_____________-------------- PACKAGE _ Ig. J oCa Capacity TYPe------------------ Material-=-fi------- � Compartments------------- Distance 5 to nearest: Well------------------- ------ Prop. Line------------------------- LEACHING LINE [ ] No. of Lines_;___,__-._-------_---______.Length of each line._----._1,_- __.__.Total Length.--------- '- p i` pial----'------------- - - YP _ r reit f• [ # Y Distance to nearest: Well------------ --------------Foundation_-__- D' Box--__._ --Type Filter Materia =------------------ e t iter atel- -�----:.P operty Line._________---.-------_-_______,_ _ r t........ _ r SEEPAGE PIT [ ] Depth-----------_____Diameter_.------ -----Number---= Rock Siz ------------------------------------------------ ti Rock Filled Yes ❑ No I 'Depth --------------= -------------------- 6 -------------------------- Distance xtol nearest:'Well. Found ato -------- - Prop. Line REPAIR/ADDITION (Prev. Sanitation Permit#---------------- --------------=--------•---- Date-- ----------------------- -- ------- 1 Septic Tank (Specify Requirements)-------- _ r-- Disposal Field (Spedf Requirements)-------- ---- ---- ------------------ --- --- ----- - -----------'----------- --------- ------ ---. ---------------------- ----------•-------- -----------------_-----'------------`--F--'---'_-'-----'--------- _---- ------------------`------------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work!will be doneJin 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 i1sued, I shall It employ any person in such manner as to become subject to Workman's Compensation laws of California." i Ii Signed --- - - - --------( = Owner ------Title -------- -------- -------- t 'fid ( (If other than o her) I FOR P4RTMENT USE ONLY APPLICATION ACCEPTED BY --- ------------DATE = ------ - --------------------- - DIVISION OF LAND NUMBER-------------- ---- ---- - ------------------ -----------------------I�--- ------.-DATE-------------------=------------- -- ---------- -- ---------------- a ,.z ADDITIONAL COMMENTS---------------------------------- ----------- �- --- ' ------------------------------ ---- -------------- - ----- ---- t y . ------=------------------------------------------------- ---- ----------- --------------u---------- ------------------ --------------- ------- -----------= = ------ ---------- ----------- ----------------- ---- ----� - ------------- Final inspection by: �r Date EH 13 24 �� SAtJ`JOAQUIN LOCAL HEALTH~DISTR T,. F&S 21677 REV. 7/76 3M } I