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FOR OFFICE USE: v FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.-�-g'__/_:e_ This Permit Expires 1 Year From Date Issued Date — ..............._-_....._--.._._..-__......_..- 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--- ._� _-____ .!.'t-.1_.-_-��__-_ � �'C-, -------CENSUS TRACT--- .... ..........._.......... Owner's Name. 'O_� !�'//" d lPhone 7�x ----------- .................. - `_ ..........................•.— Gy Address. ��_. .. e2E - -...__ !/,------ _..------------- ..... - city�.ffN_ / / �''� Zipp.1� V Contractor's Name-. -------- 4- ...�.�.�._ ._--------------License # _7��J- ......_Phone _ .�_I-. - Installation will serve: Re de ��rtment House`�Q Commercial ❑ Trailer Court ❑ Motel ❑ Other- - ............... - . ......... / Number of living units;....--__-_ __Number of bedrooms---.Z__-Garbage Grinder.....______Lot Size_.__IO�..- C!...e __._- 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❑ 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 sewe is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ] Size.._/0 --------------------------------- Capacity/aZ� _._. ...Type..........................................Material.ZA,4�4+47c_-No. Compartments...-.2-_- ..... -.-----------� r Distance to nearest: Well----- _.. _ ......Foundation.-.lam..14------------ _Prop. Line...................... t LEACHING LINE [ ] No. of Lines------/............ ...... Length of each line---_f.4`/Q.�, ...,.,.,Total Length._ _.,/i1M -:.__--- -- G/i 'D' Box...I-------Type Filter Material.tb_�WeJeDepth Filter Material...L`_y____ . ........ __.............._ , Distance to nearest: Well. - .....'a-�.........._Foundation--- ------------------Property Line. ............................. SEEPAGE PIT [ ] Depth..A2 _----Diameter.....3 6•_-__.Number.........1_____________________ Rock Filled Yes No❑ Water Table Depth--------------_------• -••- ---_ --------- ......Rock Size..Jf��-••---•-•--•---------•-I-------------- Distance to nearest: Well0_._- -----------....... ...Foundation...... ___.__---..-.Prop: Line.................. ........ REPAIR/ADDITION (Prev. Sanitation Permit#.................... -- --- .Date_..._.............................. "` ] - Septic Tank (Specify Requirements)---------- ------------- -- ----•------- -- --- ------------ ----•----••--- .V:-- ---------------------......... Disposal Field (Specify Requirements).....__ --------- -----------------------------------------------------------•-- ._. ........................................................... _-_••-•-----------....................._...............-_...__......_-•----. --------- ' ----- - . •- -_• } ' (Draw existing and required addition on reverse side) _ 1 hereby certify-that I have prepared this application and that the work will be done in`accordcnce w1tw-Scn Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son 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 become ubject to W rrkjnan's Compensation laws of California." Signed -- '---------------•---_-----1 - By........ ......................................... ..............__ -------- ----•---........._....Title..................---•-••--...........•.---- (If other than owner) 1 /FoIVDEPART)10fEl9T USE ONLY APPLICATION ACCEPTED BY....... - - DATE ---• .�� DIVISION OF LAND NUMBER...:-••--•••. ,-. '--- .• -- --- --- .........................................................DATE..----•--------------------------- ADDITIONAL COMMENTS............. ........... ................... ....................................................... ....... ... y ................................................. ....................--•------•---------..................--------..... --•---....................................._......----------------- :.:1' -t v,.. - . -- •--•-----------•............/� � ........ ......._..........._..... Final Inspection by---- ---------- .... ....................................................Date...Z; �,. ---------..----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M