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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / -/ Permit No.....7- - -- (Complete in Triplicate) --- - Date Issued.." This Permit Expires 1 Year From Date Issued A lication is hereby made to.the San Joaquin Local Health District for a permit to construct and.install the work herein described. Al? This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ? -- .CENSUS TRACT------------------- ----------- 3 --- -- ;. JOB ADDRESS/LOCA ION__... , -: .- _ -- - ----------- ---- ------------- - Phone.. ---•- 3g' Owner's Name.--- ----1• 2'__".. Zip--1: L1.'_.S `. Cit �!� -- ------------ ---- .. Address._... .._. ...... ..: .... - ,. one-- ------------------ Contractor's Name=_.. Q' r ................ License #. Residence Qfpartment House ❑ Commercial F1 Trailer Court El installation wild serve: ' Motel C1 Other... i 3....Garbage Grinder---`--- -.Lot Size._)-- Number of living units:.-- ---/.....Number of be�,d�-rogqoAm , ---------- ------Private ❑ w-C� Water Supply: Public System an name------- -------------- ""- ❑ Peat El Sandy Loam ❑ C1a Loam ❑ Silt Clay Y . Character of soil to a depth of 3 feet: Sand L� ❑ ❑ ❑ Fill Material.. -.-. ... If yes, type---.'----------• Hardpan Adobe n reverse Plot len, showing size.of lot, location of system in relation to wells, buildings, etc. m'�va'bableawi wced ithin 2Q0 feet)de.) ( p li NEW INSTALLATION: � (No septic tank or seepage pit permitted if public sew-or is Liquid Depth---- -- - --- -------- r . SEPTIC TANK [�Y— Size.-..--- --- PACKAGE TREATMENT ['] # No, Compartments----------------- --------------- Capacity-- ------TYPe---------- ---- ----- -Material......... ....... / i Foundation...... Prop. Line.. 6._... Distance to nearest: Well.'../. .,`- - --------- �-'< 'i 2� ------- --Length of each line.------------ ------�----.- Total Length .�..�F.....--•.. .................•'- LEACHING LINE . 1�No. of Lines..- l 'D' Box-._ ....1-Type Filter Materidi_j---.-. ---- Depth Filter Material__------- € ` ... Property Line.:.----�2------ .. Distance•to-nearest: Well...IQ _. -... .._Foundation.-.-2 Rock Filled Yes ❑ No ❑ ...Number- ----------•------------•--- SEEPAGE. PIT [ ] � Depth..._._.._ -_...Diameter......._ ---- - ; -,...Rock Size.---- -- ------------ i Water Table Depth-�: -----------------. . .... . Pro Line.- ' - ---- -- --._Foundation----- ---------_.._.._ . Distance to Nearest: Well--------------------- -- " r .. .. .. ....... ...............Date-- ---'----•--- -�-- ---- -� -- ...--- ---- REPAIR/ADDITION (Prev. Sanitation Permit# ------ ., ►►^ Septic Tank (Specify Requirements)-----i - ------------------ ------..........- Disposal Field (Specify Requirements). '. ..........................---- --•.----- ....__._ ........... ,,. ------ - ' -- ----- ------------ ---- == - ------- ----------•---------- ;.x ':`r';:r (Draw existing and required addition on reverse side) quin County I hereby certify that I have prepared this application and that tSan baa u nlbe done in Local Health District.t.ance with San Home owner orilicensed agents I Ordinances, State Laws, and Rules and Regulations of the f q the following: signature certifies to any person in such manner as t "I certify that in the performance of the work fob which this.'permit is issued, t shall not employ [ to become ct to W an's mpensation laws 'of .California t -... Own er,', . ----------- Signed__ -,r Signed_ . t -- ---- e ,:. (if other than owner) i ' '` FOR EPART ENT USE ONLY n,> DAT 7 .. :. --.._ - - -------- APPLICATION ACCEPTED BY '.-- ;. -� - " .- _- _ --. .. DATE..---.... ..... . DIVISION OF LAND NUMBER.:_-........ " ADDITIONAL COMMENTS"`..... - -� "' b ------ r .V �'. - ----------_----- ----- -- Date._S.~l.:- - ,..... 7/ 6 3 - ----- - ----- . . - F&S 21677 REV. 7 Final inspection by:............: . ;,. rw,Q EH 13 24 '"''' §' SAN JOAQUIN LOCAL HEALTH DISTRICT