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FOR OFF E USE; FOR OFFICE USE: II N' PLICATION FOR SANITATION PERMIT € ------[,.A�-------------- --- (Complete in Triplicates Permit -------------------------- --- - ----- -------------- Date Issued_.9=�:"��- -----------------------------............._------------- This Permit Expires i Yeaflrornt 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION. CENSUS TRACT- ------ ------------------- ---- ` , Owner's Name.. ✓ '' Address_ .................. i- f - Cit - -- - c j x-{/ --- -- -- Zi hactr's Name ---License -7— -Pone - 6. 75?®007 Contr _ Installation will serve: Residence ❑ Apartment House.E] Commercial Trailer Court ❑ Motel ❑ Other.. -- gu,Number of bedrooms_._. .Garbage Grinder`- ' `' '.-Lot Size------------------- --------- - --------------- ---- ----- Number of living units:__._._ Water Supply: Public System and,name--------------------- ------------- - --------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: -.Sand ❑. Si.lf`,❑` 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: (Noseptic tank..or seepage pit permitted if public sewer is available within 200 feet,) Q r e � tr 4_1PACKAGE TREATMENT [ J SEPTIC TANK Size_____ __X._�___._ _____._..__________Liquid Depfh._�_Y________________� ECapacity-l------------------Type._ -----Material___4< C -?----.No. Compartments- -----. Distance to nearest: Well.___.__,` 4_�_------__.___________Foundation.___60 ____._.____.Prop. Line_.._____._..__.___, LEACHING LINE No, of Lines.___ ------------------ of each lisle. f .._. .__ _____..Total Length_--- 7 U ________________________ 'D' Box-----ti.......--_Type Filter Materials ____Depth Filter Material._.__t ------------------------------------------------------ Distance _________________________f .Distance to nearest: Well_____P.r"Q__ Y` --fi-- --- Foundation---------�C�__�..- -----Property Line � - - --- SEEPAGE PIT Depth.2_�___-Diameter...- _!-Number-------- ---- -- Rock Filled Yes No ❑ Water Table Depth - -- -----------------------Rock S1ze - -�-��-f--/Z---------- Distance to nearest: Well_ X00 r' - ----- ��-- __. _.Pro Liner.__ "�__.__.__. ..Founda`tion__.__ _. . _ REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date'--------------------------------------------- Septic -------------------------------------------Se tic Tank S ecif .Re uirements _ ____________________________ ,.,-r,-.,, Disposal Field (Specify Requirements)___________ _ ___ _ _.-- - ---- ---=-------------------------- --------------------------------------------------------------------------------------------------------------- ---------- ---------- (Draw ----------------- --- - (Draw existing and required addition-'on-reverse side) I hereby certify that I have prepared this appjication 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 follovii'ing: "I certify that in the performance of the,work for which this permit i"Asty'ed I shall not employ any person-'fn such manner as to become subject to WotkMalin t; Compensdtion laws' of California." Signed ----- - - - - -------------------Owner r Title SY [lf`other than owner) F R DEPAiTMENT 5E ONLY APPLICATION ACCEPTED BY-------- _ _ --- :___ _DATE �ti:, DIVISION-OF LANA NUMBER - ---=- ----------- - -DATE = 7XX-- ADDITIONAL COMMA,TS------a ----------- ------------ ---- r t - - ----- �Q� � -------- ----- - ---- - gym__ . -------�- '` = `Z � -----� - - ----------------------------- ------------------------------Date.-Final Inspection by:--.- -- - ----- - - ----- ------------------------------------------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7776 3M