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FOR OFFICE USE: - FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No..____-7_ . S_ / S-- {Complete in Triplicate} ------------------------------------------ ------------- j'.�' / �' Date Issued _--------------------------- 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/LOCATION---l: -_ a T s lf�' :L 5.-------Alf,-------------11---- ---- ...... CENSUS TRACT-=-•--------------------- ----- Owner's Name- ---------- ----------- --Phone------------------------ ------------- Address....... e-0--7-- -- --7`SL,t '4' f- ------OV4----------------------- ------CityTn-*-Gy----- -- ---------------- Zip---------- - ---------------- Contractor's Namef A��L( 1tf-4f ._f�1��5 1a'/E'---_--J�°'o- 4__1A"A•-License #- F 3-22------Phone Installation will serve: Residence 2g Apartment House.❑ Commercial ❑ Trailer Court ❑ � Motel ❑ Other-------- ----------- ---------------------- Number of living units:---------/----Number of bedrooms-.---4--.__Garbage Grinder- ...___.---Lot ,_ 7.9s. Water Supply: Public System and name_----------------_ ---._---.-_-.-----------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe X 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 b!J Size--- ----------_-----Liquid Depth...!` --------------C Capacity.44 0-0-----Type--------------------- -Material---- -- -------------- :-No. Compartments------- ---Z- -----------------y Distance to nearest: Well.....Ido__.Q --------------------Foundation_- 1...P------_..�-1-Prop. Line---S'0 --------------_- LEACHING LINE j5(] No. of Lines-_----._-- --------------Length of each lines-----.`t_ _-_„---01------Total Length.---7__(t0-------------------------- 'D' Box--.-.X-----Type Filter Material--.-1 0_�K---Depth Filter Material-----11--------------------------------------------------- f� --Property Line---- -__---------_ - Distance to nearest: Well----/__4�---------------Foundation----J_,7_-__._____._____ .� - - --�--------- SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No WaterTable Depth -------------------------------------------- -----------Rock Size------------------------------------------------ �tr Distance to nearest: Well-------------------------------------------Foundation------------------------- Prop. Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------”------:Date---------------------------------------------1 Septic Tank (Specify Requirements)---1-fr o4 ---- ------------------------------ --------------- ---------------------------------- ---- Disposal Field (Specify --------------------------------------------------------- -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 that . the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom subje to Workma pensation laws of California." Signed---- ------ -------- ---- ----------------- --Owner ---------- -Title....-- -------- y ------------------- (If other than owner) FOR DEPA ENT U ES`_ONLY APPLICATION ACCEPTED BY_ -- --------------DATE.-.-- _. -- - ----"7 ------- ----- DIVISION OF LAND NUMBER._ ----------- DATE ADDITIONALCOMMENTS--------------- ----------------------- -------------------------------- ----------------- -------------------------------------------- ---------------------- - --------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ -- ---- - ------ - - ---------- -------- -------------- - ----- --------- - - Final Ins ectian b " Date T = � EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M