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FOR OFFICE USE: - _ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT %----- -- -------------------------------=----- ----- Permit No------ ------- - � $� (Complete in Triplicate) � �Q- 7� --------------- ---~ .. 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: -10 / 9P`off 5° /'�/�l i L e / v e - - - CENSUS TRACT------------- --------------- JOB ADDRESS/LOCATION------------------- --------------- -- - = s- y Phone'_ci Owner's Name _Q_�?.eT T.>r_- - �--- ----------------------------------------------- -------------------- ----Zip ------------ ------ '� � --------------------------------� �Sc _ e _ `�Licens` �/6L-=- f- T Phone I�f.• 3 -1/ ------------- Address-... 5 -------------- _ 7'� " v - e # = �Z/ Contractor's Name----- - /u --- installation will serve: Residence X , Apartment House.❑ Commercial ❑ Trailer Court ❑ , Motel 0- -Other_ __--------- Number of living units;------ ------Number of bedrooms__-3____---Garbage Grinder---------_Lot Size-------_______ ___-------------____.__------ Water Supply: Public System and name-------------- -------- --------------- ---------------------------------------------Private X Character of soil-to a depth-of 3 feet: Sand Z Silt❑ Clay'❑,�-Peat ❑ Sandy Loam ❑ Clay Loam ❑ \` " ' Hafdpan ❑ 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: (Noseptic tank or seepage pit pernrvtted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--�`---=j; ------ ---------------------- ----------Liquid Depth-_--y' ---------_------ Capacity_1.2 Q 0--------TYPe--�rc- e4 5T Material-----C-0-hf G------_No. Compartments '-"------ ---------------- f ..T Distance to nearest: Well------__-SQ____,-----------------------Foundation.____3_�-___.__.----.Prop.:Yine___!;.--------_---_--__. , LEACHING LINE [ ] No, of Lines________________________ ---- Length of each line-------;�7a ---------- ----.Total Length-----.�/0------------------------- 'D' Box----/-----Type Filter Material_?FvL_________-Depth Filter Material----2.0-__--------------------------------------------------- Distance to nearest: WeIL__,__ -a--______---_Foundation___--.ys-_, -___---Property Line_--''--o --------------------- ' SEEPAGE PIT [ ] Depth___-------------Diameter--------------------NumberRock Filled Yes ❑ Na ❑ WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Y Distance to nearest: Well----------=-------------------- ------Foundation-------------------------.Prop. Line--------------------------- ' - - " REPAIR/ADDITION {Prev. Sanitation Permit#-------------'"�------------`-------------------. ---------------------------------- Date--_-------------------------------------- 1 . I[ Septic Tank (Specify Requirements)---° p------------ ----- -'-------------- i� Disposal Field (Specify Requirements)----------- - -------------'-- '- ------- ------------ �_ - ----------------------------------------------------------- I — --------------------------------------------- i A _________________________________ _ __ d -------- ----------;.e_ --------- ------ ___________________________________________________________ {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 Law's,' and •Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature�certlf'ses the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ antyperson in such manner as to become subject to_Workman's Compensation laws of`Cl lifornia."; 5igned-----E.- -- -- - - - ------------------ -------------------- ---Owner By-------- " -- ----------Title----------------------------�----•--------- (I o er than o ner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- . __�__- - _ DATE------ ----------- ------ -- --------------------------------------------------------- DIVISIONOF LAND NUMBER_---------------- --- ----------------------------------DATE------- ---------------------------------- -- ADDITIONAL COMMENTS-_-- ---- ----- ----- -- - l ------------------------------------------------------------------------------------------------------------------------------------------- --------------i------------------ -------------------- -- ------------------------------------------------ ------ ----- - - _ ---------- Final lns ection b ____------Date-------- -- -- -- ----------- -- P y- ---- Ek 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 Rh' l