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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT. ---- ----- ------------------------- �.: (Complete in Triplicate) Permit ------------------------------------- ---------------- -- 1114 Date Issued_*.....14__-z� - ---------------------__--------- ---_ ----- ------ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit foconstruct 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 N.__. _r.27� { = - - - ---------- . ------------------- ----- CENSUS TRACT Owner's Name ---------- -------------- ------------- --------- --. ----`. ---Phone- 3.35 �� ------ - } Address -y�-�-- ---- --=---- - - -- ------------:City-- - Q.4-------------------------Zip- �...._0..� Contractor's Name_�C :..___ Com_. _. - ___.__---_---------------License #.c sr � /____-__Phone_------_ g- .__._�j Installation will'serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ f Motel ❑ Ofiher - ----------- l Number of living units:______f ------Number of bedrooms.._-`-Garbage Grinder------------Lot Size.__.. ________________ Water Supply: Public System and name------------- - -:- -------- --=-------------------------:=--------------------=---------------------- ---------------------------Private Character of soil to a depth of 3 feet.. Sand ❑ Silt Es Clay ❑ Peat ❑ Sandy Loam E] Clay Loam t Hardpan ❑ $ Adobe ❑ Fill Material._..______._If yes, type--- -- ______________ F (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 pif permitted if public sewer is available within 200 feet,) (7b I 7 I r PACKAGE TREATMENT SEPTIC TANK Size_____S__XLiquid Depth.- S2 Ca aclType /cam M © =No. t Compartments---2_-------------------------- t I nO / ' Distance to nearest: Well._..`-----C)_____________ __ -,.---Foundation_._ 1-0--------------Prop. Line--:-._/_---------------- --- LEACHING LINE [4--7'-No. ofLines_,--_-.3.------ ---------.,Length'of each line____�®__�________________Tota1 Length.___��_/ _._._._ ----------- �� / 'D' Box._ Type Filter Material__fit_X�__ ___Depth Filter Material____a2__________________________________________________ f Distance to nearest. Well. a( ----------____Foundation___- { ..____ -_____.Property Line---,----------------- --- No - - NoSEEPAGE PIT De th.e45_ _ Diameter_____A3-_______Number--- - -------------------- Rock Filled Yes � ❑ ! Water Table:Depth �'�-- --------------------------- -----------Rock Size_-------X- �� -- - ----------------- l / / I REPAIR/ADDITIONSanitation Permit#----_____._____ O -Foundation._.__f.�.__._______.Prop. Line.- ________________ G Distance to nearest: Well._'__. c / (Prev.,f ------------------ -----.Date---------------=----------------------- ) Septic Tank {Specify Requirements)------------------------------------ ---------------------------------------- Field{Specify Requirements}- ------------------ ------------r--------------------------------------------- ' '- J A/ -------------------------------=------- ---- ------------------------------ 1i,--------- l' y ' ------------------------- - ----------=----------- --- - - - ----------------------------------------------------------------------------=---------------------------------------------------,-a------------------------ �„ t {Draw existing and requ16d addition on reverse side} yJ. hereby certify that I have prepared his-application-and-that-�he-work-will--be--done-in- ccorda�c with-San.-Joaquin County Ordinances, State Laws, and Rules):and Regulations of the Son Joaquin Local Health-District-Home owner.o-licensed agents signature certifies the folloWing: "I cern that in the t. i "S certify performance ofrahe work For which this permi# is issued;�l she'll not employ any person in such manner as to become subject to kman's ompensation laws of California." �&. IO Signed-------- --- --- - i - 1- ------------ --------- Owner BY ` Title ---- f (If other than owner) FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY - ------------ --------------------------------------------------------------DATE ------------------------------------ DIVISION OF LAND NUMBER----------------- - ------.DATE----------------- ------------------------------ ADDITIONAL - _ADDITIONAL COMMENTS-------------------------•---------------------------------------------------------------------------•------------------------------------------------------------------. -------------------------------------------------------------------------------------------------------- --------------- ----------------------------------------------- /I Final Inspection by:__ -_ Date_--_- _ / ' '" - ----------- --------------------- - ---- ----------- -------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M