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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- ------ -- ---------- - -- 77'7.5`� {Complete in Triplicate} Permit No.-- !e Date --------------------- ----------------- -------"... ..... This Permit Expires 1 Year From Date Issued Application is hereby made to the Sgp,Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance C�with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO -.---.{.'Z_---- -------' L.--`- ------�.--------- '�'o'[ Z?-----------CENSUS TRACT--- --------------------------- Owner's Name ---- ----------- Phone ! fid T - ------- --- Address-- --------------- - ----- < �� --------c -----------City -- ----------ZiP -------------------- ---- Contractor's Name----------- ---- ---- ! „1 ----- License # �} - ` ----Phone----W_4 P= ,607_ -- Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------- --------------------- ---------- ----- Number of living units:------1-"------Number of bedrooms.._-----Garbage Grinder----_____ Lot Size___AqQ-�----Z ---------------- Water Supply: Public System and name---------------- ----- ------------------------- --------------- I .c,------------------------------------------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-------------------------------- �. (Piot 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) PACKAGE TREATMENT - - 'r ] SEPTIC TANK WS, e - -----X--- -- ---------------- : --------Liquid Depth-Sy------------ - Capacityd - _TYPe---- ----Material._C - ---No. Compartments-'----- �;--=- -- i r - ,4 Distance to nearest: Well--- --------------------------------__ -----Foundation"-------��--- a--,--:.Prop!Line_- S�7 ---------_----- g, r�tr r LEACHING LINE No, of Lines------__�---- _____ Length of each line____fir _____________Total Len th __-vzQ___,----_------_"-------- ,,]]� pp Depth Falter Material"--"_�_. _ p y�� ______ !___-_ D' Box. Type Filter Material 1 2 P `?�{}"`. .." --- - ------------- Distance to nearest: Well__ _--------- -Foundation------L_O__-f_------'.Property Line-_-��--11"--___------------ - - SEEPAGE PIT Depth___2�--_-__Diameter_ ---------Number------------------------------__ Rock Filled r Yes f' No I Water Table Depth--------------------------- - s Rock Size c ----------- - Distance to nearest. Well--------------_-_ -- f---Foundation.___-1-0------------.Prop, Line_ __-____----__._ REPAIR/ADDITION (Prev. Sanitation Permit#-------------_-___.--- -------_____--------____.Date.___.__-------___ t L t- ------ Septic Tank (Specify Requirements)------------------ ---- ---- - -------------------- :-------------------------------------------------------------' Disposal Field 4ecify Requirements) ---------------- ----- s---------------- ---------- i - ---------------------------- ------------------------'------------------------------ ------------------- -"*--_--__----_-____-_ •\ (Draw existing and req-ui e_d adaition on reverse side) :-N 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: " 1 , "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 to Workman's Compensation laws of Cdlifornia." f Signed-- --- ------------ -- ---------- -------Owner By ------------ ---'-Title-------- ------- -------------- ----------------------- ------------ (I o her than' owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------DATES DIVISION OF LAND NUMBER -------------- ----------- ---------------------------- DATE --- ------------------------------------------ ADDITIONAL COMMENTS---- --------------- }� N,�,* =- - :- --- r r ...�. :: _ � �-- i : -------------- �► �- -- -------- ------------------------------------ ---------------------------------------------- --- --- 3- Final Inspection bY:------ -. �=----------------------------------------------------Date........E� 1� ..�� -- --_ EH 13 24 SAN OAQUIN LOCAL HEALTH DISTRICT as 21677 rtEv, /�6 nn