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FOR OFFICE USE: FOR OFFICE USE: O-o APPLICATION FOR SANITATION PERMIT -------------------- �`----- Permit No.__7�-..��' � , (Complete in Triplicate) " ----------- -] �L � Date Issued_.`......-....". 7 This Permit Expites 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 compliance with County Ordinan a o. 549 and existing Rules and Regulations: o�JOB ADDRESS/LOCATI .--- -------- ------------oZ. r = CENSUS TRACT. Owner's Name... -C A=-� ? °"??_[G = Phonei �� Address. -------� 1. --- - ---- ------------------------------------- City ZiP ` Contractor's Name----� -` -- ---------------.------------------------License #_ l_ 3. -----Phone.-� -�- l C-.-- --� Installation will serve: Residence A- Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------------------------- Number ---------------------------- --------- ----- Number of living units:---.-----Number of.bedroom s_ - vG rbAga Grinder------------Lot Size-- Water Supply: Public System and name------------------------------------ p �.1/ --------------------------------------------- --------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeX 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 [ j 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------------------- -_---_-_- Distance to nearest: Well----------------------------Foundation---------------------.------Property Line------------------------ -- ------- SEEPAGE PIT [ ] Depth_--------------Diameter---------------.----Number-.-:--- --.- ------ Rock Filled Yes ❑ No❑ Water Table Depth--------------------------------------------- --------Rock Size----------------------- --------------- _ Distance to nearest: Well.-."-."'"�"----,r'--------t--------------Foundation--------------------------Prop. Line---------------------------. REPAIR/ADDITION (Prev. Sanitation_Permit# ------------------------------------Date-.__ ------ i •� Septic Tank (Specify Requirements)--- -------- ------------------------------------------------ ---/- --- --------- --- - --- ------- Disposal Field (Specify Requiremen s}_.._. -- "", _ _ - -/- --- ------- � _ ______-____"_--- ---- --------------- ---------- F---------------------------------------------------------------------- ---------------- --------------------------------------- - ---------------------------------------------------------------------------=-=-------------- - ------------------------------------ (Draw existing and required addition on reverse side) I hereby certify that I 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, 1 shall not employ any person in such manner as to become ect to Wo �smpensofion laws of California." Signed-- - -� -- ---- Owner BY ------------- j - C T Title--- -- -- ----- ------- ----------- --- --------- --------- {lf other than own ) F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- =----- -- ----------------------------------------------------------------DATE. ---------------- DIVISION OF LAND NUMBER------------------ ------------------------------- ------- ---- -----------------------------------DATE------ ------ -------------------------------- ADDITIONAL COMMENTS-----------------=- =.. - _ .. _ x _ - . ----------------------------------------- Final Inspection by______ - ______ c Date------_}_____ r = -------------------- EH 13 24 SN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7ise ann