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FOR OFFICE USE: �� N FOR OFFICE USE: =°'�� APPLIcAnON FOR SANITATION PERMI (Complete in Triplicate) Permit 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 County Ord' once No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION-- /-0.-f-- f CENSUS TRACT---- ------------------------- Owner's Name -------- - ------------- -------- ---------------------------------Phone-------------------------------------- Address------------ - -- ----------------City----------------------- ----------------------Zip----------- ----- - -- ----- - -- Contractor's Name_____ _ ___ ___ __ _ - _ -------------------------------License #_--_ / _---Phone-_-_�lvv _7_ Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court F]NI el ❑ Other----------------- _ ----------- Number of living units:__ f__ __Number of bedrooms__- - Garbage Grinder__---------Lot,Size---- _�_Y__/�--(,�_� -- _________` Water Supply: Public System and name------------------------------------------------ -------------------------------------- -------------------------------------------Private ❑ �1 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. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage-pit-permitted if-pdbblic�eweris-avaitabte within 200 feet,)PACKAGE , PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----kil- ✓ _X)D____________________Liquid Depth--------/------------------ Capacity___� __________Material____4?10--77________-_No. Compartments____ Distance to nearest: Well-----1 foundation------/_0-_ Prop. Line-----AD- LEACHING LINE [ ] No. of Lines____.__A-_______-____Length of each line______� ~--------Total Length.___/---7�________.__________ 'D' Box------l____Type Filter Material-_______ _Depth Filter Material-----/�_-.____--_-__-----__--_-____________________ _ _ _ Distanceto nearest: Well------ '_Q____ 10-U]'Inclation____�_Q__�________-.Property Line____�V__--._________-_-. SEEPAGE PIT [ ] Depth- Diameter__ _3____--_Number_-_�--__________________ Rock Filled Yes [� No ❑ Water Table Depth----- -------------- ------------------- ---------------Rock Size------{ `!I Distance to nearest: Well________ ___a---- ---------------Foundation-----------__ ----------Prop. Line______________-______-____. REPAIR/ADDITION (Prev. Sanitation Permit#__--______________________________________________Date___-_-___--__________________________) Septic Tank (Specify Requirements) ------- ---- ----- ----- ----------- ---------------------------------------------------------------------------- --------- Disposal Field (Specify Requirements)---------------------- --------------------------------- ------------------------ -- - ------------------------------------- - ---- (Draw existing and required addition on reverse side) I 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: "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 subject to Workman's Compensation laws of California." Signed------ -- -------- Owner BY---- ----- --- ---- -------- �i ------.Title----- ------- ----------------------------------------- f other, t an owner) FOR DEPARTMENT USE ONL APPLICATION ACCEPTED BY- - � - - -- - - - ------------------ DATE.---- ----- - DIVISION OF LAND NUMBER - --------- ------------------- DATE------------------------------ ------ ADDITIOL C9MMENTS----- - -- - ---------------- --- -- ----------------------------------- --------------- -------------- ------------------------------------------------------------ / ��--------- - -_�!_ ___T---------- __< -_,-------------------------- ----------------------------- ------------------------------------------- ----- ------ - - -----------------------------------------------------------------------------------------�-------- - ------------------ FinalInspection by -------- ----- ` - -- ---------- -------------------------------------------------------------------Date----- -- /-- - --- EH 13 24 SAN OAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV.