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FOR OFFICE USE: FOR OFFICE USE: . APPLICATION FOR SANITATION PERMIT Permit No.-;;f'- ----3 -- ---------- ----- ---- - ---------- -------- -- [Complete in Triplicate) - -'--�_l ------ Date Issued--��?-7e -------_. 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._ :.7. _I--_ - } ._CENSUS TRACT -- =------------ '- .. Owner's Name ---- = -' f :. _ _ one - -- r� ., .. T -------- --------- ----- Address - c ----- -- - --- =- .-,City ,_, � Zip.---- -: ,.. ' __- License #_3zZ --Phone j Contractor's Name___ ." g----- - -- � -- - _ Installation will serve: Residence . Apartment House❑ Commeraidl,❑ Trailer Court ❑ ❑ Other - ;• - ------------------ Motel 7. �• ____ ._ - Number of living units ----- _--._____.Number of bedrooms'.._"-Ga6dge Grinder___'____,,_Lot Size..,.._'_L'--- ------- ---------- Water Supply: Public System and name-.-_ .... ,- _ f Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay D� ndY Loam s Clay Loam [❑ ' Hardpan ❑ Adobe ❑ i"Fill Ma—feMa-l' If yes, type--i i (Plot plan, showing size of lot, location of system in relation to'wel.Is, build ng's, etc.�must be'placed on reverse side.) NEW INSTALLATION: (No septic tank or se "age pit permitted if public sewer is.available within 200 feet,] SEPTIC TANK ['1 Size ': 11� w --- -- Liquid Qepth " PACKAGE TREATMENT "[ ) _ � -T e __"-Materialf�•_ ._'�`'C�c'�-_'�No.•Compartments----=--�`------� -- - r.,, Capacity_ _„_Type I� i Fundption_{---rta-i �- =Prop. Line.__ - ,. Distance.to nearest:-Wei l.:, --- to '__.___Len th of each line. . Q= s. ;_ Total;Length _..,,._._. `f� i LEACHING LINE... [ No. of Lines.-_.___3__ =:: .. ., g ”" ' - I a_ ..; :",- - D' Filter MateriallFilter MateriIr ept I O .Foundation_ - -- P�'operty Line ----------------------------- P - Distances to nearest: Well_ : - - d �. k Filled N SEEPAGE PI7 [ ] Depth----:----- Diame�terNumb+ s ❑ o ❑ Water Tdb[e,De'pth--------------- -------- �--~'` ---Rock Size_ } i . Disfance'to nearest: Welt—'=- - --------- Foundation _ '-.Prop. Line REPAIR/ADDITION (Prev. Sanitation Permit#_'--------:-----------------=----- :Date_'__ = } =____ - ------- ------------ --- Septic Tank (Specify Requirements)---- :- --- _ - -----=--=---- --------- =----- - --- . -- - -. -- -----=------�-------- ---- ------` Disposal Field (Specify Requirements) y ---------------- ------------------------ . --� ---=-----= -- ------- ----- -- - ---- --------- --.--- ..---- --------- --------------------- ------------------------------------------------- -- - --- --- -------- - -------- ------ ------------ --------=---------------------------- -- d---------- :--- ------- -------------------------- -= { (D�aw existing and required addition on reverse si'Je) { 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: i "1 iertify that"in the performdnce of the work-for which' this permit is'issued, I shall not ernpioy any person in such manner as to become subject to Workman's C�.p, ation, laws of lifornia." r . Signed.-_. ------- - --- -- - - r : . -Title' Ji c (If other than owner) r s .. FOR DEPARTMENT USE ONLY } - ---------------- APPLICATION ACCEPTED BY- :----- ------- -----=------------------ = DATE.. ----- ------ - -- ---------------- =-------------=---DATE.:----------•- ------------- - :--- ----------- DIVISION OF LAND NUMBER-------------- ; ADDITIONAL COMMENTS------------------- - ----E----- ---- ------ ' ------------- ---------- ---------------------- -- r ------ ------------------ - --------------- ------------------------------ --------------=----- ----------- ---------- ---------------------------------------- Final Inspection b ----------------------------------- -= ---Date ------ --- � ? ------- --------------------------- Fos 21677 Rev. ��6 sM EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT