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5OR-017ICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r _ ,s y (Complete:in Triplicate) Permit No.._ _. ". .._.____ --------------------------------------------------------- - ` Date Issued"/d_. __._- J --------------------------------------------------------- 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ION --' y4C3 ------ __`------T------------------------------------------------------------------CENSUS TRACT------------------------------- Owner's Name-- ------- --- -------------Phone-,F�� ------- Address --- -- ---- - -----------' ------Ci _Zi �^ a 5J Contractor's Name - �---�--'G-------- ----------- ------ ---------- ---- - ------- -License #x221-S F-------Phone--y - / Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------------------- _ Number of living units:____/------Number of bedrooms_ -------Garbage Grinder,__.,/____-lot Size_ -- ' ___________________ Water Supply: Public System and name---------------------------- �J__-----e ------,.-.---------.-------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E]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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] oe J:7 PACKAGE TREATMENT [ J SEPTIC TANK DQ /VSizeLiquid Depth--- ........................O Capacity d vG TYp PL _-MateriaEs No. Compartments 07— . Distance to nearest: Well----- -------_--_-:--_Foundation..__�Q__-___--_,__._Prop. Une__6__1_0�'4-j--------- LEACHING LINE No. of Lines_____ — of each line._ _ _ __,-: ---------Total Length __-__ /_a_________________________ 'D' Box------/---Type Filter Material_ ff-Depth Filter Material-----ZV--_________________ _------------------- tIF Distance to nearest: Well___�e1 p— ________Foundation--- V--------------___.Property Lines �------ .. SEEPAGE PIT Depth._ .____._Diameter_.._33..________Number---------a______________.__ -7 �� Rock Filled Yes ' No ❑'t i Water Table Depth-------��`J-----------------------------------------Rock Size'---4;;? --------- ------ # Distance to nearest: Well_______ ____ ______ ___ ________________Foundation------- S._ .___.___.Prop. Line_. _" -'______._. REPAIR/ADDITION f Prev. Sanitation Permit#---------------------------------------------------Date.----------------------------------------.----1 Septic Tank (Specify Requirements)— - ------------=------------------------------------ --------------------------------- Disposal Field (Specify Requirements)---------- ------ -- '` ------.------------------------------------------_. ----------------------------- -------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- ------------ ----------------------- -- ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------- --------------- (Draw existing and required addition on reverse side) I hereby certify that 1 have preparedthis 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 ec to Wor an's Compensation laws of California." Signed-- ------- 4 - - � ---"------ Owner By- - --- --- --------------- Title.------ V----------- - (If other than owner) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------------------------- ------DATE ------ -------------- DIVISION OF LAND NUMBE ... - " - ------------------------------------ DATE------ --------- ---- ADDITIONALCOMMENTS-------------------------------------------- -------- ----------------------------------------------------------------------------------------------------------------- ------- '------- -- ---------------------------:-- ---- - ---- ----------------- ----------------------------------------------------------------------- ---------------------------- Final ---- ------------ Final Inspection by - ------------------------------- --- ----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M