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FOR OFFICE USE: FOR OFFICE USE: %./ APPLICATION FOR SANITATION PERMIT ................................. --. -- ----- -------- ... 7 7 /03� - -- --�---- (Complete in Triplicate) Permit fJ-o......... ---------- Date ._.... Date Issued../1 '.Z� �) .......____.._.__.._------_..._._.__--- ------ 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. Lf fhis application is made in complianncce� with County Ordinance No.549 and existin Rule a d Regulations: JOB ADDRESS/L TION �" �- CENSUS TRACT-------------------------------- ---N me.- - - - -- - . _...._.... - �d- Phone le s F 7�r- /7}�.... j� LAddress- - ------ / ` -, � '/.. -------------_City . _ .�4—' ;:.P-.Ft-------------Zip-------------------------- f - f -�. Contractor's Na " --------- -- - ..---------------------- --License #-''��?/$-,.?s ----Phone_ySo /z�i. ' '�-- --- '-- LInstallation will serve: Residence 00'� Apartment House ❑ Commercial ❑ Trailer Court ,❑ Motel ❑ Other�------------------------- --------- Number - JG.�e Number of living units:----�._._Number of bedrooms-Gar age Grinder._.__._.._Lot Size-----..____._,._._.____..._...____._..,.__..._.� Lwater Supply: Public System and name- - ---- -------- ----------`----------------- ............... ----------------------------- -------Private' Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ j Hardpan gr Adobe ❑ Fill Material------------ 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 [� Size ._. XSX .___ -------._.__._-------Liquid Depth__��----..._.. Capaci ._ YP� U P _ d ..T __..� _. -Ma �'��.__..No. Compartments �'._ . Distance onearest: Well.....-1.6 ---------------------------. Foundation_fQ._____----- -_Prop. Line._Z�_._ � r LEACHING LINE [yam No. of Lines_.ct................_._.Length of each Iine.Y4..yQ... 4._.___-Total Length_._ a.d_.7..______ Ole ,� 'D' Box_.. '.Type Filter Material S�ILIC/�.1 ..Depth Filter Material.__/�_.--------------------------------- Distance to nearest: Well__/0-6 r_.. .�..foundation- l._.._------_Property Line./._�_�.LCK'Y__...- SEEPAGE PIT [ Depth..0'..?.._.Diameter-.zz .._ _---- umber.._..3.._.__.._.._.._ d Rock Filled Ye� No Water Table Depth... - -/Q r-� Rock Size__ .X3 ------ ------- / r i Distance to nearest: Well-----1_�Q.__.___..._._.._.._Foundation...-�S_.._...-.__.Prop. Line_7._.5.......__._ REPAIR/ADDITION (Prev. Sanitation Permit# ______________Date ) LSepticTank (Specify Requirements)--------------------------------------------------------------------------------------- ---------------------------------------------------..._. Disposal Field (Specify Requirements)-_------------------ ------------------------------------------------------------------------ I .-------------------------------------------------------------------------...-------- ------------------------ ------------------------------------------------------------------------------`-------------------------------------------_..-----------. _.----....----- (Draw existing and required addition on reverse side) LI 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, I shall not employ any person in such manner as oto becom je to W4ffrr1lan's , ompensation laws of California." Signed - - m Owner }� By- - - �. �-'r- = � .e k_ --._ _Title - - - - - (If other than owner) c� FOR DEPARTMENT USE ONLY `APPLICATION ACCEPTED B - --- ---- - -----------------------------------------------DATEr2.R-7�---- -- ---- DIVISION OF LAND NUMBER-----------------------------------------------------------------------------------------------___.....DATE ------------ ------------------- ----- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------ - ----- -- ---------------------------- - - ----- 57 - --------------- ------ -------..._..--------------------------------------------------------------.._. ------------------------------------------------ ----- . ... - LFinal Inspection by:----------------- ---------- - - - ----- Date.-- - - - - - -- --------- FFF 13 24 SAN JOAQUIN LOCAL HE LTH DISTRICT Fd6 21677 REV.7/76 3M