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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Complete in Triplicate) Permit No .-...y � 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 application is made in compliance with Count Ordinance No. 549 and existing Rules and Regulations: fA�— ! JOB ADDRESS/LOCyyATyyI,,O��N..-- - �l--.-----------CENSUS TRACT ----- --------------------- Owner's Name.... �aJ/ o Ph ne. ----j- Address-- - t---------- -- --- .----------------------..--- City-- -F -- - -----�/ ��--- ----------- Zi -------------------- Contractor's --�`-----C�' � .l------- �" _- ' - p Contractor's Name_____ ------License #.- ,7_.. - _--_.---___-_ 7 Phone--_V,11( - .Z s: Installation will serve: Residence Xr Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------- ------------------------------------ // A --- Number of living units----- --------Number of bedroom _ 3--.-_Garbage Grinder------------Lot Size.-S.c6__-X� 0.6- _ -- ---_.--------------------- Water Supply: Public System and name------------------ � -----W_ -- --- ---- ------------------------ - ------------------------ Private F Character of soil to a depth of 3 feet. Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe K-o' Fill Material-----------If yes, type-------------------------------- f r..y (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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ l Size----------------------------------------- ----w---__------Liquid Depth---.---------------------- i Capacity---------------------Type-----------------------Material--------------------- ----No. Compartments------- ---------------- Distance to nearest: Well-------------------------------------------Foundation---------------------------Prop. Line------------------------ - LEACHING-LINE [ ] No. of Lines-------------------- --------Length of each line--------------------------------Total Length-----------------------------------_--- 'D' Box------------Type Filter Material--------------------Depth Filter Material--------------------------------------------------------------- ) Distanca to nearest: Well----------------------------Foundation----------------------------.Property Line------------ SEEPAGE PIT ( ] Depth'--------------.Diameter--------------------Number -------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth--------------- --------------- -------------------------Rock Size------------------------- Distance to nearest: Well--------------------------------------- --Foundation------------------------.Prop. Line-------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------- Date.-------.-------------------------------------} Septic Tank (Specify Requirements)--------------------- --------------y-----------------� --- ------------------ -------------------- ------------ Disposal Field (Specify Requirements).--� '` Q ---- ---- - h ------------------------------------- ----------- ------- --------------------------- ---------------------------------------------- ------------------------------------------------------------------- - ► (Draw existing and required addition on reverse side) . I hereby certify that I have prepared this application and that the worts will be done .-in accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the Sari 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 beco bI t to Wor t an's ompensation laws of California." Signed.---- 5. -- ----Owner By------ ------------------- ±�`� ---- ----------------Title (If other than ow r) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- DATE.. `- 7 ------- --------------------------..---- --- DIVISION OF LAND NUMBER--- ---------------------- ------------- ------------- - - ---------- ----------------- --------------------DATE COMMENTS r ----------------------I---------------------- - ----- --------e----- Final Inspection by:------- --- rr 14 ---------------------- --------------------------------- ------- ---Date. - ��--w-�� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M