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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------------------............. . (Complete in Triplicate) Permit No.....� _�.-___....... Date Issued '�.`7... ••-•-----•............................................... This Permit Expires_l 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: _ L01's L?J�7t1e�r JOB ADDRESS/LOCATION. .. ............... ............ .... C'� (°--- ...�!PPOJ-....-.CENSUS TRACT Owner's Name---------- ............ oK.yo- ......................... . ..... --- • Phone............. ------------------ Address-............. ............. Cit ..zi Contractor's Name........................CWkZ9_-................ ...............License # -------- ---------------I..Phone.- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_ .-81kP J----------------------------- Number of living units-----------------Number of bedrooms_.....-.....Garbage Grinder.............Lot Size------._.................... -------- .----- ......� Water Supply: Public System and name----- -- ---------- - --- - --------------- ---------------------------•--...---------- ---........... -------.Private M Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ Hardpan ❑ Aclobe'{j Fill Material.. -.-- ....If yes, type----............. i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {Na septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENTOO A; �� [ l SEPTIC TANK [ Size-- ----1. -----� ------ --- n --------- Liquid Depth._.... n - Capacity...l]_aCz...------TYPe--I � .....-Mot&rial----.�'C.17��rQ�-._No. Compartments 2 fA Distance to nearest: Well...........aa�?............--------Foundation------.tip ----..... ...Prop. Line....... -a-.... ._-..6. LEACHING LINE [ No. of Lines.............. Length of each line..... RU----------- .. Total Length ......QU ................_........ N ....to.�..---De Depth Filter Material....... 8... --------------- 'D' Box..--._.....Type Filter Material p 0 Distance to nearest: Well----3-� .............Foundation---------o�Q.... --......Property Line....... G._.---.............. SEEPAGE PIT [ ] Depth................Diameter---------------....-Number-------------------------------- Rock Filled Yes ❑ No ❑2F. Water Table Depth------------- }`. ........------------------Rock Size......--/...-- ---- - Distance to nearest: Well-------------------------- Foundation Prop. Line -�' REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------.--------------------------------- ] Septic Tank (Specify Requirements)--------------------------- ----=--- .................... ] Disposal 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. Home owner or licensed agents signature certifies the 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 became bie to ar an's CQm ensation laws of California." SignedY-. ..............Owner gY -----------------------------------Title._.. ---------- --------------- (If other than owner) FOR DEPARTME USE NLY APPLICATION ACCEPTED BY... . ..........DATE . ` ----------- ----- ------- DIVISION OF LAND NUMBER.--------- ---- - -------- - - - -- -- ------. . IPATE-- -------- ------- ADDITIONAL COMMENTS... st� eC .' -. - -�raD a' ...._- - Final lnspecrian by:.... Date 7 ----------- EH 13 24 SAN JOAQUI OCAL HEALTH DISTRICT &S 41677 REV. 7176 3M t i