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FOR OFFICE USE: ' FOR O IC 1 . 'PLICATION FOR SANITATION PERMIT pp ................................. Permit No.�./..�.a,.G.S.. �� - (Complete in Triplicate) ' ......................................................... Date Issued..r4.409.. ......................................................... 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 Ordinance No, 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION......... ....,. ... .. ... .........--CENSUS TRACT.................. ..... ...yL..................... . a ivT Owner's Name ...... .....J... p.... WO.51..... .;.................:.............. ........................................... ........Phone .....................................� Address............... ..... . ............:.L�..,:............. ................... .............. .....City.�Ql�.G� ... . .... ..Zip..S�..... . ..._. .� Contractor's Name.......A.,L...... <i.t:L 5'-C........:........................... 5� .Phone.�r . .. ...'lJ1� 1.. N License #.e . . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court'❑ otel ❑ Other.................... ......... / Number of living units: ...f..........Number of bedrooms-.?-.... Garbage Grinder............Lot Size........t5,oV--- . WaterSupply: Public System and name.. ....................................... ................................ . ....... .............................................Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ .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 INSTAL;ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Ili PACKAGE TREATMENT [ ] SEPTIC TANK ( ] Size..6.X.9 X. ..................... -...Liquid Depth..1:5y......... ...F1.11 Capacity/00--p.........TypefPCA Material..........................^N7o. Compartments......�.................... Distance to neca�rest: WeII....A<O...FT.. .... .........Foundation...U.d �.. Prop. Line... LEACHING LINE [ ] No. of Lines .`.7.....................Lengt hof each line..�T.........Total Length .. x..`7!4-.r............ y'D' Box.�,..... :�Ttt�e•FMter'Material. /Depth Filter prAateria .. ...��. ...................................... ....... Distance to nearest: WeII../...................Foundation..75.. ---.----- --Property Line..�rd..fT , t SEEPAGE PIT [ ] Depth.......... .....Diameter..............:.....Number................................ Rock Filled Yes ❑ No WaterTable Depth............................... .........................Rock Size.....,...,...................................... Distance to nearest: WeII..........................................Foundation..........................Prop. Line........................... REPAIR/ADDITION (Prev. Sanitation Permit#... .......... ... ..... .. .•. . --......•Date..............................................) SepticTank (Specify Requirements)...... .. .......... .............. ..................:...._.........---...........................__...................................... ......... Disposal Field (Specify Requirements) ..................... ................................ ............................................ .................................................. ........................_.............................. .................---.........---........ ................................:....----...:....................:. ........................................... ................................................................................ ....`.......................................................................................................I.................... (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 -n soC jm(pe/nsation laws of California." Signed....... -'^ .......................Owner By..................................................................................:..:..................... Title............................................ ............................. (if other than owner) OR DEP RTMEN USE ONLY APPLICATION ACCEPTED BY....... ..... . ........... ........ .. .rte.................;........DATE ......... ......-.J�.-. . .. ..... DIVISIONOF LAND NUMBER............... ............................_......_............... ......................... DATE............................... ........... .... ADDITIONAL COMMENTS.. ................. ............................ ............... ................:..... ....................................... ............................................................................... ...... .. ... .... .............................................. ....................................................... _..................... .............................I................. .......................................................0.... ... .. .. . ..... Final Inspection by:. ..............__..... . Date...-_��. '..?'.. . EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fss 21677 REV. 7n6 3M W/