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FOR OFFICE USE: ' FOR�OFFFICE USE: ' PLICATION FOR SANITATION PERMIT ,7.9.,.... .......... ,/�O .................:................... Permit No.... .. (Complete in Triplicate) 1 ......................................................... Date Issued.$..'�W.-7./q ..............................:......................... This Permit Expires 1 Year From D.at9 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............L.0T..3.P......��.� ......570, NElez0a;1f...........CENSUS TRACT.............................. Owner's Name.... ..J�' R. . &0.eS� City.T�/3GPhone..F� ....... ........ ..................... .............................. ........ ... .{.5.! ....W�Address............... . .0.�.......... --:................................'.). :Y.........................Zip ......................... Contractor's Nome... , L .f......- Phone...5 /� ...License Installation will serve: Residence] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.....................I......._............... Number of living units:.... ...........Number of bedrooms3..... Garbage Grinder............Lot Size......P�; .. . .�.................. 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, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK ( ] Size .�. -Xy.� ..X.S.......................Liquid Depth.-,:.!S7V..... (N........ Capocity�067'�.......Typel.:n F.�AS!.Material.................:........No. C��rtments.......�.....C7. Distance to nearest: Well- '0 ......... .........Foundation... Prop. Line.......3.. ....... LEACHING LINE (. 3 �7 f . j .No. of Lines . .........................Length of each line ..�Sc?.........:........Total Length . . 1��!'..................... ! ��'D' Box...�L.. ..Type Filter Material�v?�. Depth Filter Material........'. ... .......................... ......... y � Fes, Distance to nearest: Well-14YPI . .T.....Foundation...c .`...................Pro pert Line..........:........................_ SEEPAGE PIT ( ] Depth.......... .....Diameter..........:.:.......Number................................ Rock Filled Yes ❑ No Water Table Depth....................... ................... I...................................Rock Size................................................ Distance to nearest: Well......... ...A............................Foundation................ .. ......Prop. Line........................... REPAIR/ADDITION (Prev. Sanitation Permit#.......................:........... ............ .:Date..............................................) SepticTank (Specify Requirements)..... ..............................................,........ ' ....................................:..................:................................ DisposalField (Specify Requirements)................... .. ................................ -..............:............................. .................................................. ....................I............................ ._...................:............,..:.......,.............................................................. ........................................... .....................................................................................,.........................1............................................ ...........:........................................ (Draw existing and required addition on reverse side) 1 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 Son 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 t W man s Compensation laws of California." Signed........ ;Z 0f ...........Owner By--..... ............................................ ........... ....... ......._....................Title.......................................................................... (If other than owner) FOR DEPARTMENT USE-ONLY APPLICATION ACCEPTED BY...... ... : . .. ... :. . ......... ..............DATE .... DIVISION OF LAND NUMBER.................::..............................I.........._............ ..............I................DATE.:........................... . . .. . . .. . ADDITIONAL COMMENTS........ ........................... .............................................. .. ................:........... ................................. ........... ......................................................................................................................... ......... ... .... ................7: --...................................... .... .... .... �y Final InsPeciion by:_................. ... C . ..........Q ......... ...................................Date...... .. Ex to 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FQS 21677 REV 7i7e 7M