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FOR OFFICE USE: Pv �./ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ((jj � ---------------------------------------------------- (Complete in Triplicate) Permit No,;;-_ .IL_. ............................ - --' - ----- ---- � Date Issued.�� ----� 7 -------- -- - This Permit Expires 1 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/LOCA N 7 7 elT ` -- z-? �----d-o----- ------ .-......CENS.US TRACT---------- 9' ------ Te- 4Owner's Name------- - --- - Phone--------------- ----------- 4o -- - ------------- y -. .... - Zip Address 2---3- ----- ` - ..... .....- Contractor's Name------ / ------------ --------------------- Installation -- --- License #_.1.2 Z� Phone-- -------------------------- Installation will serve: Residence ❑ Apartment House[] Commercial Trailer Court ❑ Motel ❑ Other__..--t-z_ Number of living units!------- ------Number of bedrooms..--- ---Garbage Grinder...--------- Size____: ._-..a-s<----- ------._._._ r 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 [g 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 seepa pit permitted if ublic sewer is available within 200 feet,) `PACKAGE TREATMENT [ ] SEPTICgTANK [� Size. �% ._/X_._�.�._------ ----Liquid Depth.._-._.__.______- Capacity-14&Q____..Type._.,/�.cs- ar_.MateriaL.__ ._. .No. Compartments.__.�-.._.-....____.______J / Distance to nearest: Well._..d___.__ 5.6.-�._...___._____Flo/undation..._-�_O_�i�_-.Prop. Line.4^�._.._---- LEACHING LINE [''j No. of Lines...__....__-___.______Length of each line.__..._ --------Total Length------- --__.___..J 'D' Box.... ..._.Type Filter Materiak.---5_1__.Depth Filter Material.--./.7--- ----------------------------.___....__.._.__. Distance to nearest: Well--------_.D------------Foundation.__..._/._0.. .:__. .Property Line____._ _______ ________ _ / / SEEPAGE PIT [y Depth-_.2_S._.Diameter_._._- ..._Number..._.____-3--__------:..._ Rock Filled Yes No❑ ` Water Table Depth-----------_/tO------fi------------------------Rock Size---- - -------------------- / / - / P Distance to nearest: Well__-__1.49o___ ______________.._Foundation------1_6____-._.Prop. Line._.___J____._ REPAIR/ADDITION (Prev. Sanitation Permit#_..._....._.._.._._______-_..____._......Date_......_._._c,. .....'--------- Septic Tank (Specify Requirements)------------- ----- -----'-- -----------r--------- _.._. Disposal Field (Specify Requirements). -- - - - -------------------- - ----- - - 4--------------------------------------- ----------------- -------------------------------------------- - ------------------------------------------------------------------------------ -- ---� -------`----------------------------------P-----------"-'--'---PP...._.................. -'-------------'.------------------------'.----------------------------------'------- -----.... (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 accordance with San Joaquin Coun 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 become subject to Workman's Com ensation laws of California." Signed----------'----------------- ------------ - ---Owner r. BY---------------------------(Ifo her t ";,2-sp owner)-- 4 �he7sr------Title_C (If other than owner] FOR DEPARTMENT USE ONLY 1-7 r APPLICATION ACCEPTED BY---- ---`------ -- --- ---- - -- ------------------------------------ DATE.- --- _7----------- --- --- DIVISION OF LAND NUMBER------- --------------- ------- -----------------------------------'_-- ---------DATE.--------------- -------------------- -- ADDITIONAL COMMENTS------------------- ------------ --------------------------------- --- ..........---------- ------- --- ----------- _---------------- ------------------------------------ - - - -- - --------- p�q SA1V Final Inspection by:---- - ff -- - �- -- ------------ - Date � . EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT F65 216T1 REV.7176 3M