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FOR OFFICE USE: FOR OFFICE USE: i APPLICATION FOR,SANITATION PERMIT �,J /2 = ---- O ------------- --------- ----------- -------------- .-. {Complete in•Triplicate} Permit No. '7_---........... ------------------------------------------------------- Date. Issued.- 17:n 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. x This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: W JOB ADDRESS/LOCATION---- . _4 I -- : -. `�.•`��,' ;------ -CENSUS TRACT--------------------------- Owner's Name---- -. _ --------- ---`- � s --� -------- --- -- ------------- one-- -.-------- -------------- --------=----Zip------ ---------------------- - c city-.-Address. Phone--- License #--------��ntractor's a Co Installation will serve. Residence ['g partment House❑ Commercial ❑ Trailer Court ❑ l Number of livinr un•its:-: _____�__._ Nu ��- � Motel ❑ � Other-_,�____.-_ -�- -------------------- 9 t ------------------ 9 I -. tuber of bedrooms------------Garbage Grinder------------Lot Size---------------------- __- ------- ------ Water }---Water Supply: Public System and name----'----------------------- ---------=- Private Character of soil to a depth of 3 feet: Sand ❑ Silt 0 '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:""',(I\16`septic tank ,or seepage pit permitted if public sewer is available within 200 feet,) r3 k ..- PACKAGE TREATMENT -?''SEPTIC TANK- [ ] Size----------------------------------------------- - -----`-----Liquid -Depth-:------ ----- ---------"" f .. ,. Capacity-)- ----------------Type-------------- ---------Material---- -N�.°.- Co mpartments__`-------- F t ,.Distance to.nearest: Well-------------= - --- `�,----.-_. —Fouradati°n ; = Prop. Line i � LEACHING LINE [1 No. of Lines___---- __--- _..:,---_.Length of each line---.__-__------------ ---`Total Length.--.---________._____- ---.�. al------'.........'. ------------------ D' Box_ .--.-_.:.-T a Filter Material___-J`-_-;-------.Depth�Filferi-Materi } t Typo ------------------------— .L .,. . . r --:_ �`. --------------- Distance•# learas#-�h�etlr--____--- -=-=--- ----Foundation---=------ Property Line-- SEEPAGE PIT [ ] Depth----'-----------Diameter---------------- --Number------------------------------ Rock Filled Yes❑ No ❑ { Water Table Depth _--- --. ---- -- ------Rock Size---- ------= ------- --- i t ---.'Foundation-- -------,-..Prop. Line-------------------- - # Distance.to nearest: a I"._------ ------------------------_- I REPAIR/ADDITION (Prev.;Sanitation Permit#_ --------------- ---- --__-- Date---------- --- ------- ----- -- -.---1 - t { p (SpecifyRequirements) i .�//y-- - �----------------- e ---J-'-------- _ .:. moi- --__^" 1 r Se tic Tank ___.__._.-.._-_.___--_---.-_-_`- _-_-:- _ Dislposal Field(Spe fy Requirements} :.�_,-v-.__ . � ____ � 1i 5� - �F � -.---------- ----- - ----= - --- - ---- ------ ----------- ------------------------------------ --------- ^'T(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 1 r ' signature certifies the following: "I certify that in 'the performance of t e work for which#Ills p rmiF, issued;I-shall-rrot-employ any pefson-irtrsuchmanner as- to become subject to Workman's Compensation laws of California..',. . Signed-- J - - Tit � - ------------- By- --.� y -M ------- --------- ------ If other than owner) --R FOR DEPARTMENT USE ONLY APPLICATION ACGEPTED BY-----' . --- = = DATE.,.. -= DIVISION OF LAND NUMBER:----------- --------=------=------ --------= --------------- ------------------------------------- DATE -- ADDITIONALCOMMENTS-------------------- ---------------------- - -----=-------------.-------------------- ---------------------- --------------- ---------------------------------=------:-------- -----------------.-------------------- ----- - ----- - ----------- ----- -- -- ------- ------------------------ ---- -- --- ---------------- -------- ------Date --Fina! Inspection by: ---" _ = F EH 13 24 SAN JOXQU1N LOCAL HEALTH DISTRICT F&s 21677 REV, 7176 3M