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Y`' FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------------=--------------------------- --------- �- s (Complete in Triplicate) Permit No____ ___ ____ _______ Date Issued____________________ ------------------__._.__.'-- -____--___--______________ This Permit Expires 1 Year From Date Issued Applicatiori is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein dest6bed. This application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION___t_�_-�_____ ___� /l�i�. _ ------------ _ ------- TRACT---------------------------------OCI Owner's Name. U _ ------------- - r' r Phone- 6 --C� - - "°rr `. - 1' 'i -------------------------------------------ZiP Address---------- s= ---- l LJ --- city Contractor's Name . �" ` :ticense #=c3-----Phone-_ -J6d`f ----- Installation will serve: Residence ❑ Apartment House �] ,Commercial ❑ Trailer Court ❑ Motel ❑ Other.-___-__�-iJa---Le__ _ Number of living units------------------Number of bedrooms------------Garbage Grinder------------Lot Size---------------------------------------------------------- Water Supply: Public System and name---------------------------- ------------------------------------------------------------------------------------- ----------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam - rr, Hardpan ❑ Adobe f Fill Material___-.___-_.=1f yes, type___________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings,etc_ must be placed on reverse NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 - - yCompartments-,---.--.-..7 feet] -- SEPTIC TANK PACKAGE TREATMENTSize -------------------Liquid Depth Capacity- -6{70---------T1Pe-- - - - - ----- ---.ateri ' : No. Com artments. --:-------h- ------ --�-r-- -------- � /0 If- 'Distance to nearest: Well-------------------------------------------Foundation------GQr...........Prop. Line-j-- -- -------- -- 5' •_ ----------------- r LEACHING LINE [�C] Na. of Lines------- - ---- ---- of each line-------SS---------- _.Total Length------�742------------------------ �r D' Box__._`"f_Type Filter Material__ Depth Filter Material_____ ------------------------------------------------- Distance --_,_ _.________________.______________-__. Distance to nearest: Well----------------------------Foundation-----f a-----------------Property Line------------.----.----------------- rr SEEPAGE PIT � " '1 Depth-.--7----,'> --_Diameter- ----- _-------Number-------------Z ------------ Rock Fillet! Yes No ❑ Water Table Depth---------------------------------------------------------Rock Si: e. � - K-- 6-------------------- Distance to nearest: Well-------------------------------------------Foundation.---/d. ----------------Prop, Line-_----S____--`__-_-___-_-. REPAIR/ADDITION (Prev. Sanitation-Permit#--------------------------------------------------- ------------------_-----------_- 1 ------------------Date- --------- - Septic Tank (Specify Requirements) ----------------------------------------- ----------- ----------- ------ ------------- ------------ -------- Disposal Field (Specify Requirements]_.._ ___ 6."6._ _�a-__- --`�` "------------- ._ ___________________-____ ----------TIT- ----------------- ----------- ---- ----------------------------------------------------- {Draw existing and required addition on reverse side] _ 1 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 --------� --- �. ti--- ---------- -------------Title----- ,--------- If other than owner] fO)R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- `Q-------------------------------------- DATE.--------- DiVlSION OF LAND NUMBER------ ----- DAT - ---------------------------------------------- 7- COMMENTS - - - �_ ��1'�f S -------2 7$ -------------------------- --------------------------------------------------------------------------------------------------- -------------------------- ----------------- -------- .......... -------- ----- - ---------------------------------- --- --- ---------------------------------------------------------------------------------------- --- ...... -- - - -- ------ ------------------------- --------------------------------------------------------------- ----- - Final Inspection by - r .�' ----- ------------------------------------------------ Date EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV- 7176 3M