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FOR OFFICE USE: FOR OFFICE USE: . APPLICATION FOR SANITATION PERMIT --- - - ----------------- ---- --------- ------ No..-- --� - �---- (Complete in Triplicate) Permit --------------------------------------------------------- Date Issued 3"_a--.,.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. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDR,FSS/LO.CATION—:-..---. d Owner's Npme___----__S ------ I �' -------------- - Phone----------------- -------------------- AddressI✓-04 }G-------- v.cC.'- -- City- „a- "�1 -U. � _ - _ --------- s hone-IF. ip L.Contractor' f ----------- ------------- Installation will seq o: Residence E�(. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------- Number ------------Number of living units:--- --.---__---Number of bedroom Garbage a Grinder ----------Lot Size------�----- - ------------------------------ Water Character Public S stem and name------------------- -- ---- ----------------------------------------------------------------------------------------- ----- ---Private Water Su f soil tokapth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material.............If yes, type-------------------- (Plot plan, s`thowing i 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 if pub)iG.sewer is available within 200 feet,) [ TREATMENT t [ ] SEPTIC TANK [ 1 Size - qp Liquid Depth I--'V ----------(n PACKAGE TRE_ y t Capacity- =----- ------- ---Type ------------- -Material---t-------------------- -No. Compartments----------- Distance to nearest: Well--------------------- --------_-__--Foundation--------------------------Prop. Line-------, €---------- -- LEACHING LINE [ ] No. of Lines---------------------------- Length of eeUh line e+,(--I__---.---- __ Total Length -------------------- _____.__--------- NO— [ ---af . l-------------------------------------- D' Box-----------_T a Filter Material----------- � e tk'Filter Mafer:ra t Type �, p � E Distance to nearest: Well----------------------------Fdun tion.#-- --zop.rsX.ty�ine__.__�____-- ----------. SEEPAGE PI7 [ ] Depth_--.___----__Diamefier_---------.........Number Y"'_ ; Rock Filled Ye ❑ No ❑ -- --- ---- ----- - I Water Table Depth---------------------------------- ---------- _R ock Size------- --------------------' Distance to nearest: Well.--_-___.___--_____---------------------Foub.dation-------- "fir Line_----_I_--_------.----.-- REPAIR/ADDITION (Prev. Sanitation Permit#-------- ------------------------------------------Date -__ - - - - ) Septic Tank'{Specify Requirements)------ --------- --- ----- 1-� `g .. ___________________ Disposal Field (Specify Requirements).-.--..-. t-G/�C ' --- --- -------- ------,fir- ---------- ------------------ --------------------------- - ---------------------- ------ --- --------------- - , {Draw existing'dnd required addition on revere si NT hereby certify that 1 have repared this application and that the work will be done in accordance �nnth San Joaquin County i i • '_ Ordinances# State Laws, and Rales anti)6gulations of the San.Joaquin Local ealth Disirirt.Home owner or licensed agents signature certifies the following: f "I certify that in the performance of t tie work fo'r which this permit is issued, I shall n`ot eri ploy'any piirso in such manner as\ to become subject to or an's pen ation.laws of California." Signed � � - --- `'' 1.. ---Owner By------------- ----- --- --=------------------ ------------------ ------- �i --- --Title-------------------------------------------------------------------------- (If other than owner) FOR DEPART-MENT LISE-0NL-Y — — - APPLICATION ACCEPTED BY------------ - - - ----- -- -- - -- - --- ,_______ - _ti L � -`- --- -----------�---�-- E -�-s � DATE. "-�� 7 - ------------------ DIVISION OF LAND NUMBER .---. -- DATE..-------------------- - o.- R�..r ---- ADDITIONALCOMMENTS---------- -------- ------------------ -------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ ---------------------- ----- - -- -------------------- -------------------------- ----------------------- FinalInspection by:----------------------- -- -- --------------------------------------------------------------------Date------ --- v� ------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&&5521677 REV, 7/76 3M �/