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i FOR OFFICE USE: FOR OFFICE USE: ..APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- Permit No Gro (Complete in Triplicate) Date Issued._' -1-E- --7q. -------------------------------------._-.----------- This Permit Expires 1 Year From Date Issued ,�plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: �LJB ADDRESS/LOCAT � ---------- ----------- ----o-[- -- �----- 4------------------CENSUS TRACT.------------------------ I r ---------- Address ---- wner's Name----- - --------------�------- --------- ----------------------------- ----Phone--------- --------- ------- ------ Address-------- t f ------- ------ ;2) ------ -----Zi antractor's Name-- -- ------------License # --- .� -� - ---Phone------------------- ---------- rkfstallation will serve: Residence ❑ Apartment House❑ Comme ial ❑ Trailer Court ❑ Motel ❑ Other_ -__- es umber of living units ------Number of bedrooms-5_---Garbage Grinder--------------Lot Size---------Z_Q_d---- ----------- -- WaterSupply: Public System and name-------------- - -------------------------------------- ------------------------•-------------------------------------------------Private aracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Z Adobe❑ 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.[ Q- EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ACKAGE TREATMENT `` SEPTIC TANK H1 Size �� _�_-� � -----.,---- -----Li uid Depth----- ---------- -----8- Ca acitY 1aa_-fl _ Material- -_w ±t .------ Compartments.---_-"Y-------------------- q'3t I ------ TYPe._. __ _ ; .- I Distance to nearest: Well--------------4'A---------------------Foundation------- ---------Prop. Line------4------------------ LEACHING - LINE [i� No. of Lines.----------3--------------Length of each line.------4_D_f------------Total, Length ------- -.Lq__,-----_-,--__-___-- 'D' Box----I------Type Filter Material-----S-9-----Depth Filter Material-------- -�1-------------------------------------------------- Distance to nearest: Wel l--_----.$_P_............Foundation---------l h--'-_-_----.Property Line.---..+ -------------- ------ --- EEPAGE PIT [ Depth--L-S------Diameter-3 3 ii-.__--Number--------- ------------------- Rock Filled Yes No. 1 Water Table Depth------------�06---------- �---------------:--.Rock Size--- L:6_ •---- ---------------= f Distance to nearest: Well----------1 - ---------------------Foundation----jo___------------Prop. Line------ -+_-------_--- tEPAtR/ADDITION (Prev. Sanitation Permit#----_-___:-_--. ----------- --------=-------------Date----------------------------------- -----1 septicTank (Specify Requirements)--------------------------------------------------------------------------------------------------------------------------------------------- --- ------ isposalField(Specify Requirements)----- --------------- ------------------------------------------------•---••----------------------------- •---------------------------- ------------------------------- -------------------------------------------I--------------------------------•------------------------------------------------------ --------------•--------- ----------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- (Draw existing and required addition on reverse side) fhereby certify that I have prepared this application and that the work will. be done in accordance with San Joaquin County I Ordinances, State Laws, and Rules -and Regulations of the San Joaquin Local Health District, Home owner or licensed agents "I"9ignature certifies the following: j 1certify 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." igned----------------------------------------------- eo---- --- -- ---- -------------Owner cod -------- - Title &14' ------------------------------ (if other than:owner) � FOR DEPARTMENT USE ONLY�APPLICATION ACCEPTED BY------------------------------ -------------...--•---------------- - ------------------------- DATE.--------- - - ---- -------------------------- - DIVISIONOF LAND NUMBER ----------------------------------------------------------------------------------•-----------------------DATE ---- ------------------------------------------- F:ADDITIONAL -----------=--------------------------- ADDITIONALCOMMENTS------- ---- ---------------------------------------------------------------- -------------------------- -------------------- ------------------------------------------ , ------------------------------------- ------------------------- ----------------------------------- ------------------------- ----------------------- --------------------------------------------- ------------------------------------------ -------------------------- ----------------- ------------------------------------------------------------- ---------- ------- --••-------•--•------------------------- Final Inspection by----------- _-' - .- - ------- IIN ----------------------------------------------- ------Date..-� J- fes 21677 REV. 7/7h 3MEH 13 24 5AN J LOCAL HEALTH DISTRICT j