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FOR OFFICE L., E: W.- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------- ..._ _-....------ Permit NoI' a {Complete in Triplicate} ------------ ------ ----------------------------- Date Issued.- _-.AIIICS ......................... This Permit Expires I Year From Date Issued Application is hereby made to.the San Joaquin Local Health District for d'permit to construct and.instail the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: eo Cheerylb"I 5 ao Joa�pL k JOB ADDRESS/LOCATION uJ " ............CENSUS TRACT............................... �j Owner's Name.... ., Phone. ...__.... ........ . ........ ......... ........ :-- /r Ci zip ry Address ...__....... tY---------------- ,rfi�rr -- Contractor's Name.-...-.. . . ....License #- ff��l.�.......Phone-. ..� ------ Installation will serve: ResidenceItel Apartment House ❑ Commercial [-] Trailer Court ❑ ❑ Other----- - ---- -------- -------- Number of living units:......1..........Number of bedrooms .. Garbage Grinder............Lot Size.--CiI •..------ Water Supply: Public System and name.. ..... _I——--------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam t , . . Hardpan E] Adobe ❑ 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,) PACKAGE TREATMENT [ ) SEPTIC TANK .[ .] _ Size.w - - ------------- ------- Liquid Depth.--------....-.-- ----� x � ents.-- ------ .................. 7yp . Moteriol.� W--------_-J No. CompartmCa Capacity../_40-i e. . . . 0 .-- .-._ Distance to nearest: Well.------ - -- --- ..__..-Foundation---.-/0. -.._...... . Prop. Line.. ................ .... LEACHING LINE j ] No. of Lines �-------.- ..length of e�_C/ :_�.De line.----�. .----- Total Length . -- ------------- ----------- �iI 'D' Sox..... Type Filter Material- - --� . th Filter Material_... Distance to nearest: Well Foundation------------------ Property Line....---------.-------- , - �-� . SEEPAGE PIT `[ ] Depth....pr.,��..Diameter..-------- ----Number..__---��,--.._......--.-` Rock t=illed Yes ( No EJ Water Table Depth-------- --------- - -Rock Size. ------ ----------- ,.. j� _ .. Distance to'nearest: Well.--...--_.J'_"_ _ Foundation-.y--------------- Prop. Line..-.---- ..... REPAIR/ADDITION (Prev. Sanitation Permit#..-------------------------------- - ......-Date----....:..----------------------------.------) e Septic Tank (Specify Requirements)----.--- ---- - ------- --------------- - Disposal Field (Specify Requirements)---------------------- -•---- --.-__....--. ......... ------------------------- -f------ -------------------- -.....--------------- -.._-....-----------...-----•------------------------ ................ -- ------------------------- -- -------- ---- -------- ----------•--_ - ' (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." i Signed.`---.. .. ' .-. .... -- -- ----- ----------- ----....Owner �( BY ...... ... -- -..... Title.------_----_- ----------- t7_ if other than owner) FOR,DEPARTM NT USE ONLY APPLICATION ACCEPTED BY----- - �?i.........- DATE % - . ..�..... .--.. DIVISION OF LAND NUMBER......--- ------ ---- -.DATE.- ....... .. .... . .... ADDITIONAL COMMENTS. - -------- ---- - ---------------- -----......... .--- -------.-.... ...... -........._........ . ............. .............. . - . .... ......... .......--- - •--------------- I ---------... ... .......... ---•.............. -- = ........... ...k, .. - Final Inspection 6 ' ' y � y:............. /L�,'/L-L.. Date.... I F&S 21677 REV, 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH TRICT