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-AOR OFFICE USE: FOR OFFICE USE: , , r APPLICATION FOR SANITATION PERMIT -------------------------------------------- - p (Complete in Triplicate) --------------------- ----------------------- - � Issued_-�-`�--�/ •-------------------- - - --------------------- --------- This Permit Expires 1 Year From Date Issued bate 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. �5449 and existing Rules and Regulations: JOB ADDRESS/ ...... -- .. ---------- / !/4---P�- P------ -- --- r _ h d T CENSUS TRACT �� --------- ~`� - _ rFle-------------- -- - ---------------------------Phone--- Owner's Name.---- - . !�= Address.-:- -- -- -- 'IV L> �F _ -- - -- - -- I ------- - -------------City_ _��,/W � ,*I,t7 ZiP--------------- -------------- Contractor's Name -: _KGs../"'ff - ...--------------------------------------License #��67J-54---Phone---67675"–?�� . Installation will serve: Residence I Apartment House ❑ Commercial ❑ Trailer Court ❑ _---_--Motel ❑ Other.------------------- --- --------------------- 01 - Number of living units:-_ ------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 ❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material-. -._-----If yes, type-------------------------- (Plot plan, showing size of lot, locat on_of,system'in:refsition,to wells., buildings, etc. must be placed_ on reverse side.) z _ NEW INSTALLATION: No septic tank oi•-see ( p ,� pa`ge��pit permitted if p4blic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ` f � ---------------Liquid Depth-- -------------- Lapacity)�G,V-------TYPep/AA - aterial-- --------------------.--No. Compartments----- 1`1] i I JDistance to nearest: Well--------- ----N_:__,_------ -_- -_:Foundation., J- .----_ _______ __'Prop Line____ _ _> P P - --------------- LEACHING LINE I ] No. of Lines__.3----cwt---_--"'___.Length of each line__-��_:f--�_-----.Total Length.------P��- _ ` O ---- ' fes' 'D' Box./'_--_--..-Type Filter Material IAOX� 0--De th Filter Material--_:_ Distance two nearest: Well----------------------------Foundation--/jer-f----------------Property'Line------1.6---.---.--_-- SEEPAGE PIT [ ] Depth----------------Diameter_------------------Number_____ -------------------------- Rock Filled Yes ❑ No ❑ WaterTable,Deptl�°------------- -----------------------------------------Rock Size.----- ----------------------------------------- E Distance to nearest: Well---------- --------------------------------Foundation--------------- ---------^Prop. Line------- ------------------ REPAIR/ADDITION (Prev. San itatiorYPermit# -- ----------- _ - _ ------------------- -_---_- Date.--.---------- -------._______-----1� — _ Septic Tank (Specify Requirements}------ �rdar ` �`----------------------- Disposal Field (Specify Requirements) `rwc.�!- -------- -------------------------------------------------------------- }------------ -_-I---------- ---------------------------- -----------•-- --------------- -------------------------------- ----- -,--------------------------- ------------------------ -------------------------------------- ----------------------------- ------------- - -. j (Draw' existing and required addition-on reverse side) , 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 followi g: "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 rkrpn's Compensation_ laws of-Calif ' E-�� Signed_. -------------- iOwner s BYE ------------- -------------------- --- -----------i Title------------------------------- --- --------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY i ------------------ ------------------:----------------------_--- DATE. DIVISION OF LAND NUMBER---------------- ------- ------ ------------------- --- ----- '...DATE.------------------------ ADDITIONAL COMMENTS_--------------- ------------------------------------------------------- -------------------------- -----------------•------------------ --------------------------------------------------- -------------------------------------- ---------------- --- ------------------------------ ------ - - - -------- A ---------------------- ------------------------------------------------------------------- --------------------------------------- tFinal Inspect --- - - ----------- ------------- --------------------------------------- ------------------Date----- --------- EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M