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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- --- ------- [ Permit No..7Z.-.3_�T..0. Complete in Triplicate) ----------------'__. .....----'- Date Issued.g�--"-7Z ----------------- .............. 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 O�rddinnancee - ------ No. 549 and existing Rules and Regulations: `JOB ADDRESS/LOCATION.....0Z / b- _S0-` ` ----CENSUS TRACT ------- Owner's Name.----- - -- - �.(�j/ - - - - - - Phone---------------------------------- -Addr-Address--------------- C ess ----------- City------------------------- --------Zip-------------------,-------- Coniractor's Name---_ C -_ _..... License #., _ L_Phone._.�jl�... Lb.Y- 1. ------------------- _Installation will serve: Residence /Apartment House[] Commercial ❑ Trailer Court ❑ Motel ❑ Other_- ------------------------------------- Number of living units:_._/-------_Number of bedrooms----- Grinder------------Lot Size-._.7__d?----- _--- ____.._. 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]] 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,] 7/ .PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Q Size...__. __ _ _X - J O_ Liquid Depth._ . Capacity) _0.0___-Type_...�d-------.-_-Material-_ ---------No. Com artments_.-_- -------J i ---------------Foundation_-.__ . ----_---------Prop. Line---� _ 0 Distance to neatest: Well -- �t7 C'[!I_____.....__ 'LEACHING LINE [ ] No. of Lines---_1-__._..__.____-Length of each line.______ -G----____.Total Length.._..�.>7--------------------- _ to 'D' Box------------Type Filter Material_..../_Depth Filter Material_____J.,S_.._.------------------.-------- .---......_ Q,�,,� Distance tonearest:Well__10 V__ :-:.-_.Foundation...-4--___..___..._Property Line__.Jdl2--------------- SEEPAGE-PIT [ ] Depth-r�e210-6 9_eter._______..__..._-Number_______ ___________--------------- Rock Filled Yes No Water Table Depth---------------------------------------_---------------Rock Size----#- --------------------------------- Distance to nearest: Well_........l.d_D--------------- ____---.Foundation--------------------------Prop. Line----------- REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------------_------_----.Date---------------------------------------.) `ieptic Tank (Specify Requirements)-------------------------- .............------------'------------------------------------------------------------------- ---------------- -------- Disposal Field (Specify Requirements).-..--- ----- ------------------------------------------------------ ------------------ . ..-'----------------`-----------------------------'------------------ ----- (Draw existing and required addition on reverse side) hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County .-Drdinances, 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 .,o become subject to Workman's Compensation laws of California." Signed. - - --- - - - - Owner ---------------- By --------------Title----------- -------- -- ------ - - - -- - --------------------------------------- I oth an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY._. ___... _ _ _ F __ -- -7--------------------- -DIVISION --- -- ------ - DIVISION OF LAND NUMBER------------------------ - ---- DATE--------.------_--------------------- - --------------------------------------------------------- ------ ADDITIONALCOMMENTS.------------------------------- ---------.------------------------------------------------------------------------- -------------------- ------------------------- --------------------------------------------- ------'------------------------------------- -- ----------------------------------------------- ---------------------------------------------.--------- ----------------------- ---------- ------------------ ---------------------------------------------.._..------------------------- - - - - - - - ---- ------- -------------- --------------- - - - =inal Inspection by: -'-`--'------- - ` -- - ----------------------------------------------------------------------_-..-Date e ----- ------------------------------ ._en 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F83 21677 REV.7176 3M