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} � FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------I---------------------------- ------------ Permit No.� r-53� (Complete in Triplicate) ---------- --------------------------------------------- Qate Issued7--.a-,2:r2_ ------------------------------------..--- __-. ._..... 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 Ordin n e No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.... _?-- L._ - -------------------------CENSUS TRACT.-------------------------------- Owner's Nam _ -----------Phone--------------- ---------------------- _ -- -. Address_ _ ---- - ----------- ---- -----------�------ ---- -- ----City-- ------ -------------------- ----- ziP �► - �^y Contractor's Name----- 0 ----------- -License #..a`_ one ------------------------------------------ - ��Ph ��`��l Installation will serve: Residence ❑ Apartment House❑ Commercial ❑ Trailer Court ❑ // _ Motel Other--------------- ----------------------- ----- Number of Iiving goits�,--/--.----Number of bedrooms------------Garbage Grinder------------Lot Size`_- ............... ........ ----------------� fi IN s Water Sup'I PLblic S`ystfijm c�nd name-----'-- ------------------------------------- ----- ---- -----------------------------------I--------------- ---- Private Character'-nf soil to a depth of 3 feet: Sa,nd ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ r —� _ ' Hardpan ❑ Adobe M.. Fill Material.-.__.._ _ .If yes, type___.- ------------- ti -- (Plot 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,) S PACKAGE TREATMENT [ ] S 'PTIC TANK ( ] Size--------- -------------------------------------------------Liquid Depth.-------------------------- Capae itY---------------------TYPe.. --------------------Material--------------------------No. Compartments-------------------- -------------- Distance to nearest: Well------ -------- ---Foundation--------------------------Prop. Line------------ --------- LEACHING LINE [ ] No/of Lines--.`p----.•'T-------Z-._.Lendth of each ling- -----------------------------.Total Length ------------------ --------------- 'D' Box----------:.Type Filter Material------------------.Depth Filter Material----------------------------- -----.-. .----.--N Distance to nearest: Well----------------------------Foundation----------'- ---- -Property Line------------------------------------ SEEPAGE --------- ..SEEPAGE PIT [ ] Depth---.-------- Diameter------_-___..------_Number-- ---------------------------- Rock Filled Yes ❑ No❑ WaterTable Depth---------------------------------------- -•--- -----------Rock Size----- -------------------------------- Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line--------------------------. REPAIR/ADDITION (Prev. Sanitation P rmit#------ --- ---------------- ----- Date._..___.__...-. ---------- -- -Septic Tank {Specify Requirements)- �O� -`� ----- ----------------------- Disposal Field (Specify Requirements)---------- --- �------—--------------------------------------------------------- ------------------------ £, I ------------------------------------------ --------------------`-----------------'-------------------------------------------------------------------------------------------------------------------------------------------------------------------------- {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: f "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 becoject to Wo an' om ensation laws of California." m Signed....(_�Signed---. - --------- -- -----------�-�-- �- ---- ---' - ----------------------------Owner Lam! --------- ----------=--------- --- --- -- BY ----------------- _Title------ (If"ot er than o ner) FOR DWRTIAENT USE ONLY APPLICATION ACCEPTED B - �---- - -- --/--- - -------==-- - ---- ----- --------- -----------DATE -- ------ ----- --- ---------------- DIVISIONOF LAND NUMBER----------------------- ------------------------------ ----------------------------- -----.DATE---------I---..--------------- ---------------- ADDITIONALCOMMENTS- ----------------------------- -------- ----------------------- ---------------------------------------------------- --- -------------------------- ------ --------- -- ----------------------------------- ------------------------------------- -------------------------------------------------------------- --------------------------------- ------------------ ------ ----------------- ----- -------------------------------------- -- ------ - --------------------- - --- --- - -- --------------------------------------------------------------------- --- ---- .Z� Final Inspection,b t Date._._ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7176 3M