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FOR OFFICE USE; FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I ----------------- ------ ,2..2 S` (Complete in Triplicate) Permit No.______ Date Issued-- -------------------------------------------------- ssued-....-----._--------------------------------- ------- -- 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: 714 ss' E- L acx { JOB ADDRESS/LOCATION. . ........ .... ... --- -------- ------CENSUS TRACT-------------.-.------- f Owner's Name)l.// 1� ,y �.-R ---4- - — -- - -----------------.Phone------ -- ------ Address.1,l�` �J ------E'G_ -- --- .... ----- Ci ------------------------zip------ _ i Contractor's Name. ----- -- - ------ -------- 1$41 . License #__ r'ZZ � Phone .--�- t � I Installation will serve: Residence ❑ Apartment House Commercial ❑ T oiler Court LlMotel ❑ Other----.. tom- r Number of living units:------—-----Number of bedroom's.-.r-.---Garbage Grinder------------Lot Size--------------------------------------- ------------------ Water - _.._._._Water Supply: Public System and name------------------- ----------------------------------------- ----- ----------------------------------------------- --Ffi*ate ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt p Clay ❑ Peat ❑ Sandy Loam ❑ Clay o,,-M. 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.) 1 �,NEW INSTALLATION: No septic tank or see age pit permitted if public sewer is available within 200 feet,) ENT SEPTIC TANK ,/ [ 1 [� - �5ize_�/�.��-�-.��-`5-�--'---------------------Liquid Depth.- /, -- --------- - ) ��ACKAGE TREATMENT - ` Capacity-42PW---------Type -Material-----��`�� ---------No. Compartments----�------------------- v a ` Distance to nearest: Well---------------l41¢,1.. ............Foundation------/_iP_ Prop. Line----- LEACHING LINE No. of Lines----------/----------------Length of each line'..___ . ............Total Length----sqo�.-------------______--. ; 'D' Box---------Type Filter Material----- _ _-----Depth Filter Material-------- ------------------------------- ---------a. Distance to nearest: Well____./_dtG_�--.----_.Foundation---------_�'1f} ____.Property Line_______S�`" _--______--.h- SEEPAGE PIT [i� Depth. . __.3�_��__Number----.---_---_/-_____________ Rock Filled Yes e N Diameter._ _ Water Table Depth.-------1 --------------- i------.Rock Size ---------------------- Distance to nearest: Well.-----_---fSQ --.-_.-____ ---Foundation------La ---------.Pro Line_.---�.t_� y EPAIR/ADDITION {Prev. Sanitation Permit#___________________________________________________Date______________.._____. _ - Septic Tank {Specify Requirements)-- ------- --------------------------- --------------------------------------- ----------- DisposalField (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 Son laaquin -CCU 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 14a By-------------- ---------------------------------------- -- (a2 Title --------- -------------- --- --- ------------ Of other than owner) FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY_..-- -_a,,� --- . ------------------------------------DATE.-----?-P------------------ DIVISION OF LAND NUMBER____________________ _ ADDITIONAL COMMENTSDATE.-..--.___...---_..____._ ------- --- ------------ ----------------------------- -------------------------------- - - -- --- ------------------------------------------------------------------------------------------------------------------------------------------- - ---- -- ----- -- ------ ------- ------- ------- ------------------------------------------ --------------------------------------------------------------------------- --- ------ -- ------- --- ---------------------------------------- ----- - -- --- ---------------------------------- - ------------------- ---------- �} - ---------------------------------------------- - - - ------ ---- Final Inspection by - - .- -- - __. Date / = Eli 13 24 SAN'JOAOUIN LOCAL HEALTH DISTRICT iF&S 21677 REV, 7/76 3M