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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No............'._..._._- Date Issued.... :._�7:. -------- 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. Thi 9pplication is m de in com 11 nce withty Ordinance,No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT N...__f _ IPti!Lr7`IAY'�aJ�= ._.lGt:.:•'. 7aQT=-;�"CENSUS-TRACT:--.- Owner's Name.... ��--------•• .. , --- - - -- -- ... ... ........ .. .Phone __....... --• ------- Address. . 7 ....- f�/. 1�° City...--.--- ---� -� rL . .. .. � ....... Name... ....-- License #- Phone ontractor's Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other--- -.............. . f----------- Number of living units:..... ..."__Number of bedrooms-_-.� . Garbage Grinder..... r3 p g ...Lot Size-----.. .�... � �:�.".:.'-- - - Water Supp[y: Public System and name...... Private --------- Character of soil.to a depth of:3 feet: Sand Silt El Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan F 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.) r NEW INSTAL;ATION: (No septic tank or seepage pit permitted if pvblli sewer is avpilable within 200 feet,) t PACKAGE TREATMENT [ ] SEPTlC TANK { [ ]r .4 Size.. .. -------- ---.Liquid Depth....'....----- Capacity-.-/�Q.+�7�ype...p/P,��c' Material .. .� �fJo, Compartments _-. ..... Distance to nearest. Well--..------ ^-------.--_"---.Foundation.......7.6-_._.. ......Prop. Line- ------tzl� LEACHING LINE [ ] No, of Lines..._® -------- k.-....Length of each line..5-0----..-- Total Length . � D' Box---1__-_Type Filter Material 2Depth Filter Maters 1.....j9'.............. . . ^� �7 Distance to ne�1►est: Well "-. �( .Foundation...... �5....._...__.Property Line.... r�2..__.`:�.--....._. ".. SEEPAGE PIT [ ] Depth_.oz - Diameter.-i--65---------Number-------3------------- ------- Rock Filled YesA No f M Water Table Depth.- /0.0 ----------- ---- --.Rock Size----- .- -- - --- ----- 1 -4 Distance to nearest: Well..'_ I— -.- ---I........_...--------Foundation_- ...--�5...._Prop. Line--- ....... REPAIR/ADDITION {Prey. Sanitation Permit#---------------- ---------------pate........................... _ r Septic Tank (Specify Requirementsi...................... :- -.'--- I- --------- Disposal Field (Specify Requirements)---...... .. . - -,- . .-- - � `------ -- ......................... --- ......... ................... *` ------------------. _ _................................ ------- �.............. (Draw existing and required...addition on reverse side)y I hereby certify that 1 have prepared this application and that the work 'will'1be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents j signature certifies the following- "I ollowing"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 i I to become subject to Workman's Compensation laws of California." ' l Signed------- w; s ) ------ -•- ----------------------Owner By.. ------- --------- . T,itle, 1 (l# other than owner) � - DEP RTMENT USE ONLY j . f APPLICATION ACCEPTED BY------------ .... . ---- DATE .. �.� ... : . . . ! . DIVISION OF LAND NUMBER............ t ..... ............ --- ---- --- --DATE.---......... . a ADDITIONAL COMMENTS..._"................. . #-------- ---------- ...... y, - -------------• . -. ................................ ........ ............................................... ---------------- - ----------- -- - ---- ----- Final Inspection by:.... Date.. .. . : ... . EH 13 24 i!'— � a S,4kfqJOAQUIN LOCAL HEALTH DISTRICT 45 21677 REV. 7176 3M �E