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FOR OFFICE USE: FOR OFFICE USE: /APPLICATION FOR SANITATION PERMIT ------------------------------------------- ----- ------ (Complete in Triplicate) Permit Date Issued_-=,1��_ 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 withCountyOrdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION--------1�C -��y------------ - 1 I�----------- ---- ----------- _ ,r;— --CENSUS TRACT----------- - ----. Owner's Name. 7 `�� /✓�t�5 j _ �� ------- ----- - ----------------------------Phone_ l�o � Address.--------- J fn - =.�:�+ 1! ' 'S------M?---------------------- --Ci _PA-1: Zi Contractor's Name----------- _____________________________License #VVI 52 ....Phone- Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------------------- ----- Number of living units_____L_________Number of bedrooms`-3_._.__Garbage Grinder_----__-----Lot'Size------- --- --- -------------,----------------- Water Supply: Public System and name-------- --------- ------------------------------ - - ------------ -----------I--------------------------------------------------Private Character of soil to a depth of 3 feet: Sand E] 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 if public sewer is available within 200 feet,) C PACKAGE TREATMENT [.], SEPTIC TANK Size. Liquid Dep th y . --------------- _A!1&0 -. Typ e4_57-Material _ _No. Compartments.____Ca Capacity cam Distance to nearest: Well ._ ,2_.�_____________________Foundation_. ---_ _____Prop. Line___1-6-__�r____.� LEACHING LINE [ ] No. of Lines.__.__ -----------------_ _.-.Length-of each line---_. �- .. _ Total Lent �� Q' 'D' Box-, ---Type Filter>Material_�� Depth Filter Material.__________ _` _ F �---------------------------------------- j Distanceao nearest: Well--/�" _ ;---_----Foundation-__��._� ____Property Lirie_._ _ _ _T-----_____. SEEPAGE PIT [ ] Depth_-_i_.____.__Diameter__--------_---------Number------------- --------__-_______ Rock Filled Yes ❑ No ❑ Water Table Depth--------------------------------------------------------.Rock Size-------- -------------- ------- Distance to nearest: Well-- ------------------------------- Foundation-------------_---------- Prop, Line______.________-_____._.. REPAIR/ADDITION (Prev. Sanitation Permit# `'�— -.Date__.________ ___________ _-.__F________________ -- ------- SepticTank (Specify Requirements)------- -----------------------� ,-------------------------------------------------------------------------- ---------------------------------- DisposalField (Specify Requirements)---------------------- ----. ------ ------------------------------------------ ---- ---------------------------------------- t --------- --- -----r------- - (Draw existing dnd 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 "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 ,"kman' Compensation laws of California." Signed - .-.__ - __-..._ -- Owner Y-------- - - --------------- -------------------- ------------ --------------- - Title--------------------------- (If other than,owner) r .FOR DEP TM N E ONLY APPLICATION ACCEPTED BY-. - / DATE. DIVISION OF LAND NUMBER - ------- ---------------- -- ---- '--.----------------------------- `--- DATE - ADDITIONAL COMMENTS--------------------------------------------------------------- ------------- ---------------------------- ----------- ------ -------------------- ------- -------- ------------------------------------------------ ----- ----------------------------------------------------- -- ------- - - --- -- - ---- ---------- -------------------------- -------------------- - - - ----------- ---- Final Inspection bY= --------------- -- Dat +__ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M