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FOR OFFICE USE: FOR OFFICE USE: ; ' APPLICATION FOR SANITATION PERMIT ----------------------------------- Permit No....7_7------------ -•. (Complete in Triplicate) ' Date Issued__/..' __..__._.__ --------------------- ------- ___-____-_________ 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 ADDRESS/LOCATION.-'.. {----- �1 -------------------------------- -- = -.CENSUS TRACT ----------------- ---- -- - Owner's Name----------- -� ------- --------- -- --- Phone. d � Address / - � ,=L� ------------------------ City zip R # h' __ .-_ - 3 - - - Contractor's Name-.!____. ._, '-' - W '__.- License°#td� ---Phone_..` ----_.=* . �'..,. Installation.will serve: Residence" ' Apartment House.❑ Commercial ❑ Trailer Court. ❑ _ }� _-t.._.. Motel I7 Other---------- ---- ---------= -- ----------- Number ------- ` "" Number of living units:_ Number of bedroo s�___G.arb.age_ dnder Lot Size.__., :__.aC----------------------------------- V ; �s Water Supply: Public System and name_____.--__-" -. ___-_ _.__ .__rte'' ____._ ------ --- 1-------------------- Private" Character of soihto a depth of 3 feet: : Sand ❑ Silt❑ sClay ❑Peat"❑ Sandy Loam ❑ Clay Loam ❑ r t Hardpan. ❑ Adobe Fill Material,1_-____`if,`yes, type----------'------------------"-- •" a I - , t. (Plot plan, showing size of lot, location of system in reldtion to`wells, buildings, etc. must be'placed on reverse side.) NEW INSTALLATION:' S;.[No septic tank or seepage-,pit permitted'if.public sewer is available within 200 feet,) i PACKAGE TREATMENT' [ ]" 'SEPTIC TANK Size; .__ .. __ ------------F__._________Liquid'Depth.:_.____ _..____._ C I apacitypQ____;TYpe f Mat�rial_ � � ��__.___._No: Comp artments------------ rx� ----------- ------- - ...-.Distance to nearest: Well aFoundation.___ d_____________Pro Line__________ __I f _ � - _ p LEACHING LINE � . No.. -Lin s _ - ! _- Length of each line !1"�_ _ - r Total Len th {,U --------- __-_____ D' Box Type Filter Material_'! � epth Filter Material - .____.._........................ __..__.-_________ .. + Distanca to nearest: WeEI.=___ -_Foundation_. __. --_ __ ___._.__.Property Line_- �_____:�� Y `_- SEEPAGE PIT r De th. . .s - ---:--- Number_-___ --------_-'.-- -' Rock Filled .Ye No ❑ P. -� --.Diameter = Z Water Table'Depth--- Q = _ .Rock Size'i -!Ae --------------------- i ! 7 �- l t Distance to.nearest: Well_.__ ___ __ __Foundatio` _ __ ----_------Prop. REPAIR/ADDITION-(Prev. Sanitation-Permit#-y'"` r --------------------------- - :Date ='- - _ Septic --------------- Tank (Specify Requirements[------------= ----------- -�- V '' = - =----- ------ ----- _ ' = -----, ------------- --------- Disposal Field (Specify Requirements): -.- - -- - ---- ---- --------- ----------- =-------------I------------>------------------------------- --------------------------- 1 Yrt 7--------------------------------------------------------------- ----------------- - - -------------------- Draw existingsrnd.req.uirsd_addition - -= - ------� •----------------------------------------------------- ----- - € { on reverse'side) i 4 I hereby certify that 4 have prepared this application and that the (work will be done in accordance with San Joaquin County l Ordinances, State Laws, `and Rulesaand Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: ij " ; _1 certify that in'the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become_subM51-1-6 toorkman' Comp ; sation .laws..of California." +4 i Signed = Orwner� . � �� i ; $Y-1 - . r �'� "r= - ------------- Tit) (If other than owner ih ' FOR DEPARTMENT'USE ONLY APPLICATION-ACCEPTED BY '- DATE. - DIVISION OF LAND NUMBER_.. .. _ -_ ) _ :__._._.__DATE ' -- ADDITIONAL COMMENTS _4 �fJl +� j- --------------- - - ` � r - / " = , # - ----- ------------t• ---=-- - --- ---- _------- f ---------------------------------#---- - `-----'------=- ---- --------------------- -- ----------------------------------------------' ------ ------------ --- --- -- ------- / ' Final Inspection b -- ry -----=---- - ------"------------ e-.-Date--- •�=..r EH 13 24 SAN JGAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/�3!�__!