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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------------------------- (Complete in Triplicate) Permit ---------------------------------------------------..____ This Permit Expires 1 Year From Date Issued Date Issued__J. 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-- --------- -------------�fi! f CENSUS TRACT Owner's Name. ,,�� 3:� -- _ E4x_s—_ -��'7/�7�------ ---------- -------------- ---- -------- --- Phone-- �'� 1------ �5 `. .qs+� 'I OZ.S _�'-_1 T Cir 4C Zip r,. _ Address-__.- __ __-__ -Licen�� �s - --------------- Contractor's Name. - �1Z1.1'r/_Z_ rF—------------------------- ---------- ------------ se #p� _.1�.��or�_Phone__ .��' j Installation will serve: Resident-'$6., _Apartment House ❑ Commercial ❑ Trailer Court ❑ —rMotel ❑' Other______________ Number of living units:-_--__--------Number of bedrooms3-__.__Garbage Grinder__---------Lot Size-----A-� 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 to4 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,} 0 PACKAGE TREATMENT [ ] SEPTIC TANK [ ] 1 r �� sr ' -------------------------- Liquid Depth ------- b _ -Material________________________ No. Compartments_____ Capacity.1�49z; --_Typ�t(' __-__ ----- S _ . Distance to nearest: Well---- _ <-.-.________ �______Foundation_ _��__.Prop. Line_-__ca��__�� _ - ------ LEACHING LINE ( ] No. of Lines_._ ---------------Length of each,Iina.__.__6-"4_T'_____.Total Length ----1_,2.15-11 l Ile D' Box----1------Type Filter Material , epth Filter Material ------� -_.E_______.__-------------------------------- 1=i 1. -----Foundation _______________Property Line--- _____ --------------- Distance to nearest; Well- SEEPAGE PIT [ ] Depth----------------Diameter------------- -Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ------------ " Rock Size s Distance to nearest: Well------------------ --------------------Foundation------------------------.Prop. Line._-------------------------- 1 � . REPAIR/ADDITION (Prev. Sanitation Permit#----------------------y _r___________.________.Date------------------------------------------- --- Septic Tank [Specify Requirements)---- --------- -------- t Disposal Field [Specify Requirements]_____________________ ---------------------------- ----------------------- --- -------------------------- ---------------------------------------------------------------------------------- -------------------------- - ----------- ----- JDraw ------------------------ - {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 erformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject o rkman' Compensation laws of California." Signed---4r -`_----------- - - ----- ---- ---------- - ------------------------Owner BY-------------------- --- ---------------- V - Title-- '` ------------------------------------=--- (If other than owner) F A USE ONLY ------------ ----------------- APPLICATION ACCEPTED BY__.___ .--------------------------_DAT DIVISION OF LAND NUMBER ----------- -------------------------------------------- -=---------------------.DATE------------------- - - ------------------------ ADDITIONAL COMMENTS----- ---- --- } -- ------- --------------- ------ --- - ----- -_« - ------------------ :,-,A---------------------- ------------------ ------------------ ------------ ------------------------------------------ - --- ------------------------------------------- - ------------------- -------------------------------.,^---------- ---------------------- Final Inspection b _ _ -----------------------------------------Date- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7 0 M