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f , FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No..... Date Issued...._1^_Atf-715 •-•-•-•------ ---------------------- ------ This Permit Expires i 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: • r . JOB ADDRESS/LOCATION..��..� . . ,�f -��-��i�.� �------- ------------- ------------ -------CENSUS TRACiT�:./.1----•-- Owner's Name.... -/—.//V ......C:7--... - ... .. - - - --. - Phone... Address----.-. City .-- -TZitP ��- -----�--- - - Contractor's Name..............dr /rf_ -� .......-...-_ ----License #-------------------- Phone... ...�&.757c. --... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other-- ----- --- ----- ------------------------ Number ----------------------Number of living units:..-.......Number of bedrooms__... .. Garbage Grinder------.-..--Lot Size..- Water Supply: Public System and name.. .... .... - - . .-.........--.-_--,_.-._....Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe [}J, 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j W PACKAGE TREATMENT ( .] SEPTIC TANK . --..--..� I ] Size -...- - - --- ---------• -----------------..._._..... Liquid Depth---------------- Capacity.... ---- ------Type----------_--- ------Mater•sal---- --- ----------------No. Compartments _-------------- ...... Distance --- -----•-- Distance to nearest: Well--------------------- -- --- ---- ---------Foundation......... . ...... .. .. Prop. Line............ --..--__. .. s � � LEACHING LINE [ ] No. of Lines ------.---. Length of each iin r .5.__._..._. Total Len�r th . _..�.�...................... 'D' Box....../. ..Type Filter Material.,5 ..-- epth Filter Material.- ._.....�........ Distance to nearest: Well------------- Foundation--------------------_ .....Property Line-.-.---....... .... :....---.--.-- SEEPAGE PIT [ ] Depth..- s1r..--Diameter.-_ 1_6.. .....Number .---------t----------------- Rock Filled Yes Or No Water Table Depth--------d.? .......----- ..---- ---_.............Rock Size..././S 1_ ------- ---------------- Distance to nearest: Well------------------- --- -------------------Foundation...... ...... ..-Prop. Line._ ---..------._-.- REPAIR/ADDITION (Prev. Sanitation Permit#................................... .... ..........Date----------......-----.-.----------..---------.) Septic Tank (Specify Requirements) . - - ..._ - ----------------------- ------ ----- Dis osal Field (Specify Requirements) ---.-------------------.....__................. ••-------- ------------------ . . ... ....._.. -----......_..- - ---......----....--- -------------------------- -------- .......... ..-.......... ---- ------ (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, Horde owner or licensed agents signature certifies the following: "I certify that in the performs a of the work for which this permit is issued, 1 shatl not employ any person in such manner as to became sut7je t to Work an ComRensat<on laws of California." Signed...... '.__. '. ...Owner By.............................. ................. --- ---------.. ............. Title .......... --- (If other than owner) f R DE ARTME T USE ONLY APPLICATION ACCEPTED BY.......... .. .. . DATE ...... DIVISION OF LAND NUMBER.............. . .. ........ . ........... ........ DATE................. ADDITIONAL COMMENTS .1_ _Y .- -.2.I- ..... .. .......... ......... ... .... --------------- ......- -- ..... ......... ------- - ----- -- ---------- Final Inspection by:...... -- ---- cns ....... - --- _-- -- --- - Date.----- z-. .5c--- ---------- ----- EF1 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M