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L FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �7 ---- (Complete in Triplicate) Permit No.._. ....-/_..-,57 / ---------- - .. ---- zt 74 .__ ._... -------- This Permit Expires 1 Year From Date Issued Date Issued. 6�_ -Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 54499 and existing Rules and Regulations: JOB ADDRESS/LOCATI �-z - p /C�/ --_ CENSUS TRACT Dwner's Name...__ .. ae -aQBev_.-..--- --. -__ --�c-t------- - (' - - _ o - 3��Address-------- Zip - ----------------- Contractor's 3-/ -- Name.._.._ license # Phone .nstallation will serve: Residence ❑ Apartment House[] Commercial ❑ Trailer Court ❑ i Motel ❑ Other.../rtac.Qu..-----------'------------- Number of living units:----- __-Number of bedrooms_!__-Garbage Grinder --Lot Size------�t� _ 4G -- -------------___----------- r Nater Supply: Public System and name----- ------------------------- ----------------------- _ -Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam El- 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,J i 9 ,,,,PACKAGE TREATMENT [ ] SEPTIC TANK [� �_�,p Size-._....J-XS��___�....._.____Liquid Depth_..��__.---- ."._-- Capacity-�'Lb V------TYPe---1`--�-`'-'---------.Material---CPAs.--.----No. Compartments.--- ----_---.---- / r � Distance to nearest: Well---__17©.-_.__-----------------Foundation.-__/0__-------- Prop. Line._4W�_-.....--..__._.C� 'LEACHING LINE (� No. of Lines..... ------------ Length of each line...___�o.__....."...__Total Length..._. �-�...............__.__. 'D' Box/L/"-T a Filter Material /':90,r r YP / O v, ,,&e )epth Filter M?aterial--------------- -----------------�--------------------- r Distance to nearest: Well_.._[_j..- . -...__.Foundation.__1d_.___..___._Property Line.l®........__.___------- SEEPAGE PIT p 5 �6 r� Z [- No ❑ � Depth Rock Filled Yes Water Table Depth----------z- ............'----------------------------Rock Size--- - -ii------'---'------- Distance to nearest: Well__ o?G_I---__.__..___._.._._Foundation----- 5 --------- Prop. Line_.�0. - - REPAIR/ADDITION (Prev. Sanitation Permit#.... ..___ ---------------------__------------Date-___-.. ---------------.------_____--- y3eptic Tank (Specify Requirements)---------------- -------------------------------------'-'- ----------------- ------------------------ Disposal Field (Specify Requirements)--------------- .--- ,_, r (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County a 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 +.to become subject to Workan's Compensation laws of California." " Signed--------- --- --- -- -- ----- - - -----.._......--Owner . By--------- - - -- Title -ecvlt t (If other than owner) FOR DEPARTMENT USE ONLY yAPPLICATION ACCEPTED BY--/---- -- ------- - -- -- - ------------------------------------.---DATE --- -- -- - --- ---�----- -f--- DIVISION OF LAND NUMBER.--------------------------- -- ---- - -- --- ---- - ----._--------------DATE.----------------- --------------------------- ---- --- ADDITIONALCOMMENTS- -------------------------------- ---------------- - - --- ----------------------------------------------------------- --------------------------------------------------------- -- - --- -- - --- - --- ------ ----- ----- ------- -- ---------------------------- - - Final Inspection by:-..._-_.... -_ ..._v ___. ... ........ _--- - -- - - - - -------------------- - - ------- -- ---- Final r H 13 24 SAN JOA OCAL HEALTH DISTRICT F85 21677 REV. ]pti 3M