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r FOR OFFI_GE SE: FOR OFFICE USE: L. f(�C! APPLICATION FOR SANITATION PERMIT ---------------- -------- 1 �-- --------- g (Complete in Triplicate) Permit p / --------- ------------- --- ---------------- ------ .:..---.,. Date Issued--�:---..-..--- -------------------------------------------- This Permit Expires 1 Year From Date Issued pplication 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. 549 and existing Rules and Regulations: m �, � gJOB ADDRESS/LOCATION._./O W CENSUS TRACT------------------ -------------- ner s Name ; Phone_ ?3/_0 �-- I{ Ow � - - - 01 Zip Address-------------- ------. .... ...City-- _ ;Contractor's Name-------- .' ---- -------- -----License #.�>. -- Phone..' " _ Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 Trailer Court ❑ _. Motel ❑ Other---------_------------------------ Number ------------------ --Number of living units:.. ,- . Number of bedroom's �,'" Garbage Grinder: -Lot Size- .- .............. ........ ...... ... is = �• e ,.-Water Supply: Public System and„name ....___-- --------------. -------..Private ❑ -- .:- - — ----- Hardpan ❑ Adobe ❑ SlFill Material-..--.-.. elf yes, typendy Loam ❑ Clay Loam ❑. ,,,Character of soil to a depth of 3 feet: .,Sand ❑ ❑`' y ❑ ❑ ---------------------------- (Plot plan, showing size of lot, location of system' in relation to wells, buildings, etc. must be placed on reverse side.) ANEW INSTALLATION: (No septic tank-or seepage pit permitted if public sewer i5 available within 200 feet,] _ PACKAGE TREATMENT { ] SEPTIC TANK P41 Size.._-. -fz.V- _---.------._-------------------Liquid Depth._ tr._--------- Ca acit /2�-----..-T e._---_ C�r-----Material---C ------No. Compartments..-.- Distance to nearest: Well--.----�0 ----------------------Foundation_-__140.-------_-__--.Prop. Line...------- ---;----.--- --- LEACHING LINE Na. of Lines.....---------------------Length of each line.:<6...4.. _____.Total length ------7 -- --_-------------- or P D' Box.....%._--Type Filter Material-9.— ---.Depth Filter M'afierial----- ---------------------------f---------------- -------” r DistancE+to nearest: Well.____$`Q----"�----_.Foundation---------rQ.._#..._---..Property Line____--�`-...._._-_-._..-. SEEPAGE PIT De th.-� -._ Diameter_____. -.. . << t p -- �_'-_'_Number-------- ----- _;: �IRock Filled Yes No ❑ nearest: Well Foundck Size --1 - -- '= j Water Table Depth ------------------------------------------------- 00 Distance to a Q fdtion-.--. �...� " Prop. Line...`"�--...._---------- p (. I Y„.. G_ Date..".",------------------------------ ---- Septic --- Setic Tank S ecif Re uirements}:_:- --:---------- ------------------ ==' = - REPAIR/ADDITION Prev. Sanitation Permit ........... Disposal Field(Specify Requirements)------- 3- ---------------------------------- --------------------- --------------------- ---------- ------- LJ -------- ----- -------------------------------------------------------..- ----------- ------------------ ------------------------------=-------- - ----------------------------------'-------------------------------------------- --------- -- -------- -- - ---------- (Draw existing and required add ition,'.on_rev.erse side] I hereby certify that 1 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 to become subject to Workman's`; Compenscition laws of California." Signed- ------------- - -1- - ------- ----------------------Owner ---- -- ---Title-- ., .. t .. .(lf ... ..- __- ___-....-...-.-_.__-_BY ------ --- ----------- other thah owner) FOR DEPAiT ENT SE ONLY 1 APPLICATION ACCEPTED BY. "� = �L -- ---- ------- DATE DIVISION OF LAND NUMBER.. ----- --------------------------------------------------------- DATE:" = ` ---- ---- ----------------------------------------------------------- --------- J ------------ . --- - -- ---- -------------------------- - ---- ------------------------------------- - ---. ------ --------- ---- -------------------------------------- ------------------------ -- Final Inspection by: ----------- --- ------- - --------------- _ - ------- Dateff �_ _..-. --- ------ ---- I " EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M