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FOR OFFICE USE: V FOR OFFICE USE: _ �.APPLICATION FOR SANITATION PERMIT "'le ------------------------------- p (Complete in Triplicate) Permit - Date Issued--. =� -------------------------------- _ . ------------- 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 appli on is made in compliance--with County Ordinance No. 549 and existing Rules and Regulations: �0/3 j sh4v _ JOB ADDRESS/LOCATION N--�'� ----- �� ---�- S ------- ----------- -------------------CENSUS TRACT-------------------- 17 Name------- -c� w� ry s u�-2 JT S Phone - ------------- ------- ----------- ---- Address------------------------------------•------ gr"V-_e�r✓hl- .(2_7hc -------------Ci Go ( Z - --------------------Zip_--------------------------- Contractor's Name-----7t7k/l...... ........... ------------License #_ 0 ` --.-----Phone-i - ---Z�/ ------ r..Installation will serve: Residence❑ Apartment House.❑✓ Commercial D--Trailer Court ❑ Motel ❑ Other--------------------------------------- - Number of living units:------Q-----Number of bedrooms-------�-0----Garbage Grinder---�.__Lot Size ________ r.Water Supply: Public System and name---------------- --------------------------------------------------------------- ---------------------------------------------Private Qi Character of soil to a depth of 3 feet: Sand ❑ Ot❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe�—E/ 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.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size------------------------------------------ - IrA ----------------------------------------------Liquid Depth--------------------------- Capacity---- U..__ Type.� .Gs_ MaterialC-e�YY +2No. Compartments______Z _________________� _ 2� Foundation Distance to nearest: Well___________________ ------- Distance _ _ _ _ ------------Prop. Line----- -_---------___. ' LEACHING LINE [ ] No. of Lines______.._____ `�� _______.Length of each line------- _ .__ ___________. .Total Length .-------17jo_____________________ 'D' Box------/- �--.-Type Filter Material__12_. s .Depth Filter Material + .__________ -----------------------------__.. r Distance to nearest: Well__.__?i__©_Q-----------Foundation-------J_Q_._..______Property Line ---------------------------------Q SEEPAGE PIT [ ] Depth_._-Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑W WaterTable Depth------------------------------------------------------_Rock Size----------------- -------------------- Distance to nearest: Well-------------------------------------------Foundation _ _ __ _.__-______--__.Prop. Line---- _-______--. REPAIR/ADDITION (Prev. Sanitation Permit#___________________-_--_-.____----____------__.Date __..__.________________..__.) Septic Tank (Specify Requirements)--------------------------------------------------------------------- - ----------- - --- - - ------ Disposal Field (Specify Requirements)_------ ----- ----- ----------------------------------------- - -------- - ---------- ----------- - ------------------- ----------------- ------ - ----------------------------- -------------...--------------------------------- -------- ------ _... -------------------------------------------------------------------------------------------- ----------- (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 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 subW kkman's Com/pen ion laws of California." Signed -/t� � ``" ` ' W Owner By - ---------- --- -------------------------------------------------- Title '- (If other than owner) F DE2AR MENT USE ONLY APPLICATION ACCEPTED BY--- - DATE_ DIVISIONOF LAND NUMBER-------------------------------------------------------------------------------- ------------------------DATE------------------------------------------------ ADDITIONAL ------------------- ----------- --------- ADDITIONAL COMMENTS. -- �, ------------------------------------------------------------------------------•-•-------------------------------------------------------------------------------------------------- -- -------------------------------•- ----------------------------------------------------------------------------•------------ -------------------------------------------------------------------- --- - - ------ ---- -------- -------------- ----------- ---- - Final Inspection by:------- ------- - - - Date. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 2MV. 7/76 3M