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FOR OFFICE USE: APPFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r�y --------- Permit No ---S`� (Complete in Triplicate) Date Issued7__ ��T --------------------- ---- ------------------------------- 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/LOCAT O' d -----------3 a- ----.-..c------- -�-------�--------------�------� -------------------CENSUS TRACT-------------- ---r- �/ ��Y _ Owner's Name...----`• � -- -------- - ` -f-- -/s Address-------------- --- -1 -3_;l. 5 1� "' " City- -_Zip �� d -11 ✓` . -i_- e7/"-;F-. ------ -- ---------- Contractor's Name- --------- License # �7/ - -.Phone CJ� Installation will serve: Residence [l?-"Apartment Hulse.[} Commercial ❑ Trailer Court ❑ / Motel ❑ OtherL ------------------------- --- �/ / Number of living units:-- f----___-Number of bedrooms...,-__GGarbagee Gr''nder- .__.____ _Lot Size---------� 1` ____.___------_---------- Water Supply: Public System and name--------------- ------ —(T [------------------------------ -------------------------------Private ❑ , Character of soil to a depth of 3 feet: Sand ❑ 5ilt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ I Hardpah ❑ Adobe X 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.) tV NEW INSTALLATION: (No septic tank or seepage pit permitted'if public sewer is available within 200 feet,) Ly .-. PACKAGE TREATMENT [ ] SEPTIC.TANK [ ] Size.________- ._._______._________Liquid Depth---------------------------m Capacityn,7:n--------- -----Type_-�- -- Moterial=- 'T ------- -:No.,Compartments----------------------------------- r Distance to nearest: Well-------------------------- ---------- Foundation----...... _ _-- -Prop. Line--------------------------_/ LEACHING LINE ['] No. of.Lines----- ---------------------.Length of each line------------------------_ ---.Total Length.------- .----------------------------i i 'D' Box------------Type Filter Material--------------------Depth Filter Material------`-- ---------------------------------------------------- Distance ------_-._ ._Distance to nearest: Well----------------------------Foundation______________.------_---._Property Line-.----_-_---______________-_-.__ SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑ WaterTable Depth-------------------------------------- ----------------.Rock Size------------------------------------------------ [ ------.Prop. Line Distance to nearest: Well_---------------------------- ---------------.___________ REPAIR/ADDITION (Prev. Sanitation Permit#____________________--------------------------- --------- ------------.Date--------------------------_------- ---- ------ Septic Tank (Specify'Requirements)------- Disposal Field (Sp cify Requirements)_,._ ___ - ----._�.l`:"'Y''------------------------�--------------- -,-- ---------�------ ------ Sr i -- --------- - ---------------- ------------------------------------ ------------------------------ I---------- ---------°------------------- ---------------------------------------------------------- j (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 tho' following: ] "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 jec to kma 's Compens000n laws of California."'- Signed. alifornia."'-Signed- F ------------- Owner -------- --- ------ By------ ------------ ------- -`-------------------` ---- - ------Title--- --------------- a (If other t n own/r)i t j FORD ARTMENT'USE ONLY-~-~^-r--~- APPLICATION ACCEPTED BY____ _ ___ ___________ ___ DATX.- _._ - --------------------------------------------- --- --- -------------------- DIVISION OF LAND NUMBER --- -------------------------- - ----------..DAT -- -- - -- -- -------- ---- - - ---------------- ADDITIONAL COMMENTS ..---- ------------------------------------------- - ----- ---------- ' ------------------------------------------------- i i Final Inspection by:---=. ----- ------------------------------------------------ - ---------------------Date. =�f= --- -------------- ---- EH 13 24 SAkJOAQUIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 71 6