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FOR OFFICE USE: FOR OFFICE USE: L APPLICATION FOR SANITATION PERMIT ry ------------------------------------------------------, ' /' (Complete in Triplicate) Permit Na��— fl_1___ -------------------------------------------------------X Date Issued/ -/,;L --------------------------------------- ----------------- 4 This Permit Expires 1 Year From Date Issued Application is hereby made to the Son `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/LOCATI --_Q-'- - - -------------------CENSUS TRACT------------------ - Owner's Name...---' - = ' ` -- -------' Phone6_'_ 7/ ---------------------------------------- ' Address---'--'--- ..... �7iG�---------------------------------------City -----------------Zip------------------------------ Contractor's Name------_--P—(_.__e -------- --- --------------License 04�__ 1;75'5--------Phone_yG 7n07___---. Installation will serve: Residence X Apartment House❑ Commerciai ❑ Trailer Court ❑ ! Motel ❑ Other------ --------- ----- --- ----------------- Number _____ --___Number of living units;------4--------Number of bedrooms --*-----Garbage Grinder------------Lot Size------/- �---177-_-._______._-____ Water Supply: Public System and name--------------------------------------------------------------------------------- ----------Private } Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 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. mustbe placed on reverse side.) NEW INSTALLATION: NT [Noseptic tank or seepage pif permit edif publi+ sewer fs available within 200 fee#,) t� � : ].-�-SEPTIC TANK ?q Size----------- _k Liquid Depth. :. Capacity-/ o----_---Type-- ----------Material---6 ----No. Compartments---__'Z---- _ , r . ly � Distance to near`est: Well._._,-1 .,------------ -----------Foundation_-----tO-_------------Prop. Line_u~__r*_______- .. LEACHING LINE No. of Lines-- �------------------Length of each line.--.____-F0_- Total Length ___l ___ ------------------------ D' Box---[/.-Type Filter Material -_. _---Depth,Filter_Material-------<_______---________________________ Distance to crest: Well------C-_I Foundation_____ _t- ----------Property Line_______-. v---------------- SEEPAGE PIT De th - Diameter___ �,41P( , Rock Filled Yes No i P Number a -` i Water Table Depth------------------- ---------------------------- ---Rock.Size-- J r1 r P or Di stance to nearest: Weli_____- _�f --'---------'----------Foundati$�n _--= =----------.Prop. Line. '_ .�----- -i - REPAIR/ADDITION (Prev. Sanitation Permit#------ --------------------------------------------Date------ --,..- ] I -------� Septic Tank (Specify Requirements)---_------------------------- — - ` Disposal Field(Specify Requirements)--------------='` --r_-:__'_-- _____- 1 ___________________----------------------------------.-- -------------------- -------- --------------------------------------{_____------,_____.------------------------------------------- - x {Draw existing and required addition on reverse side) 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: T "I certify that in the performance of the work for which-this.permit_is-iss.ued,:1` shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed-------------------------------- ---------- --------------Owner 144B w ther than owner) --- -- --------- _Title OR EPARTMENT USE ONLY APPLICATION ACCEPTED BY ", -----------------------------------DATE ---- ------I 7?-------- DIVISION OF LAND NUMBER.__- -__.DATE.---_- .--.---.,-.--_ ADDITIONAL COMME ------------ ---- ------- ---------------------------- ------------------- -------------- Final Inspection b ------------------------------------------------- -- -- - p Y----------------' •-� Date - Q -�_7. - � - -- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &S 2k577 REV, 7/7h 3M