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FOR OFFICE USE: FOR OFFICE USE: '"'• APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No...-71`.�� d .�' Date Issued--- ................. `-----r�...-:. .._._-. ......... This Permit Expires 14ear From Date Issued Application is hereby made to.the San Joaquin Local Health Dist'r`ict for a +permit to cnsteuct and install the work herein described. This application is made in compliance.with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA ION..--. .-�-�-- i -- - -- ------ --- --- --- ---CE u ,Owner's Name... Phone -.- - ---. ---- -------- Address-.. ----- Address Ci - ..... ------- Licen`s#�/Q � Contractor's Name----.:� :: .. "' _- Installation will serve: Residence ❑ Apartment H use ❑,'Commercial ❑ Trailer Court ❑ Motel ❑ Other_._>�--------- - -------- ------------- Number of living.units:__._.. ----- Number of bedrooms_...---'.... Garbage Grindar.........---Lot Size-/..... .............. _... ........ _.-_--... _.. . _ Water Supply: Public System and.n,ame_. _,2- '" = = # --------------Private ❑ Character of soil to a depth of.3. feet: Sand❑ .'Silt 0 Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ - Adobe.❑ Fill Material _ ..:- ---.If yes, type--_-:_. -----•-------- �. Plot plan, showing size of lot,,location of system in relation to v�ells, buildings, etc. must be placed on reverse side.) NEW INSTALEATION:• [No septic tank or seepage pit permitted if public sewer is available within 200 feet,♦ PACKAGE TREATMENT" I'] SEPTIC TANK ..........Liquid Depth---- _.-- W [ ] Size -- -'- -- ------------------•---------- - ..... Ca +cit T� e___--•-- --- Material;-------_ -. No? Compartments...... -_._ ._ Distance to nearest: Well------•:--... .. ...... .....'p.......Foundation-------- Prop. Line........--___.-----.---- LEACHING LINE [ ] Nor.,.ofvLines ----- --------•-----------.Length of each line.............................. Total Length 'D' Box.. ........Type Filter Material. -.< Depth Filter Material ----._. ---------------------............. Distanc&to nearest: Well- ---------- ._. --. Foundation;`-- .-------- - Property tine----------- ---- - SEEPAGE PIT [ ] Depth....-__.- -' I-Diameter_____...............Number-.-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth. Rok Size...... Distance to nearest: Well............... .- --------Foundation_.-- : Prop, Line-------............... .. . f REPAIR/ADDITION (Prev. Sanitation Permit#--------------------- DpEe----------------------=----'..---:.----.--___-) Septic Tank (Specify Requirements).--- - .... . .- - ------------ Xtl------- - ------------------------- - ----- - -- - Disposal Field [Specify Requirements)_..:. _ .------ . Y Y .._...- ------------------- ------------------------- i - -- .,[Draw existing and required addition on reverse side] 1 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 !hot 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 ompensation laws of California." Signed--_ " Owr . ne By......... •.- .-.. . Title.. ........7(lf other than owner) OR EPART ENT Ug ONLY APPLICATION ACCEPTED BY ... ------- --------------- DATE ...._._ r••.. . DIVISION OF LAND NUMBER._. -- f .------ ................... _... ADDITI / - ._ - - ------- . -- � .. . ' ... j .. - . -, - _________________ _-__ I Final Inspection bj-S'7 y:..... . .......... ... ..........-.-----------------------------------------------.....------...:-----=-- 1 -...Date. ----�---------�- �........- -- .. . -.. ._ - E" 13 saSAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV 7176 aM