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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r/ ------------------------------- ------ - A . (Complete in Triplicate) Permit No._�T Date Issued____. --------------------- ------ -----------I---------.----- 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: JOB ADDRESS/LOCATION--------- -C - -----------�a0 � CENSUS TRACT. Owner's Name------- - A- - ��J--- ------------------ ------- - -------------------------------------------------------------- -------Phone---------------- ----- Address.__.___."."".._ .-_ = c�-�� --------- --- �----/------- --------------------------------city - �=1V,t_-Lc,++��-��-_ -----zip-��--�'��----- Contractor's Name--------- --------------------------- ---------------License #r ?�' � C� --Phone Installation'will serve:�'! ;� `Residence ❑ Apartment House.❑ Y Commercial Trailer Cour Motel ❑ Other---9-A-77 Number of living units:_Np�umber of bedrooms AMOFarbage 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 PK Clay Loam 0 Hardpan ❑ Adobe❑ Fill Material-_ .._5.;.._lf yes, type-------------------------------- # (Plot plan, showing size of lot, location of system .in ridrd-Tion to ,�buil.tling's �etc, ust be placed on reverse.side.) NEW INSTALLATION: No septic tank oriseepage "piny` tpermit?ed if public sewer isgavailable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK�l S]• Size___ _ � �, _ ��-- -�;�-�- - - -- - ----------- Liquid Dep#h--��`-�---- ----- Ca pa '� p Y Aawil TYAe ate�ial sNo. Compartments �/ _l- - � � Irl l ----------- Distance/to nearest: 1Nell.__�iP _______________________ ___Foundation.. __._`'_-.___________.Prop. Line_._____________-_. LEACHING LINE [ ] No. of Lines "_________."__= ______.Length of eai line_ , - ."" .Total Length-------1Q_---------------------- D B i i I f ll ' ' ox------------T a Filter Material+/ �a,e�.De the-iter Materia!___-- -/-- ----------------------------- Distanceto nearest: Well-/ +-------------------Foundation_---------/------------Property Line--:------------------------------_-.� SEEPAGE PIT [ ] Depth_------------t._Diameter---------------____-Number--------__-_____-r-/------__ Rock Filled Yes ❑ No❑ Water Table Depth---------------f--------------------------- [ --- � � 1 � �.�--Rock Size---------�'----------- ------------ -- Distance to nearest: Well = _"""_"_- ------Foundation_____ "_.._--------------Prop, fine--------------------------- REPAIR/ADDITION " ""- ___.-----------REPAIR/ADDITION (Prev. Sanitation Permit#__ :--_a"______---° --------------Date---------------------�"-_" )t Septic Tank {Specify Requirements)------------- .----- --- = <,--=----------------------'--------------- ---- ------------------ ' <ar - - Q Disposal Field (Specify Requirements).. == ' �► ----------------------------------------------------------------------- ------------------------------------------------------- w {Draw existing and required addition on reverse side) ¢ I hereby certify that I have prepared this application and t cit the work will be done in accordance'with San Joaquin County Ordinances, State Laws, and Rules and Regula.tions.of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: � I "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 become subject to W�m�anompensatio-n laws-.of ,California." Signed------- ` ` ------------------------ -----------Owner - BY =!---- -------------------------------------- -- --- ------------- -- y--- - --Title-- ------- -------------- j (if other than owner) ORD ARTMENT USE ONLY APPLICATION ACCEPTED BY--- = DATE. .f - --�--------------------- DIVISION.OF LAND NUMBER - ---------- ------------ -------- --------------------------------------DATE ADDITIONAL COMMENTS".._ �1� ------ r ,c ----------- ----------------- ----- - (/ -- ---------------- ---------------------------------------------------- ------------------------------------------------------------------------- ---------_�,�-_. r----- --------- x___. � - w r_ ------------------------- FinalInspection by:---- __ ________ Date. �� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M