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FOR OFFICE USE: a ' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .. - - -- ------------------------------ Permit No...,c-r'-`-��` c-• - (Complete in Triplicate) - ----- -------------------- -- ------ ------ , ...._...:.......:........................._...__. -- __ 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... " ------- G ---------------------------------r,�.1 •-- l- ,-- CENSUS TRACT--.. - ---� k i F ' Owner's Name....:. .. _ ✓ ?r_'' - Phone: F_:!!_ .` '. ..... ---- ---- . ....ZpAddress.... . City........ ... � .. .. r h. Contractor's Name. . .......... ........................... ... -License #---- - ...Phone..--.. Installation will serve: Residence ❑ Apartment House.;L Co mercial �Trailer Court ❑ Motel ❑ Other_____ fR d r Y g -------.---.,Garbage Grinde,r_.....__..__Lot Size..__... . Number of living units:............ ...Number of bedrooms___ __.._....__..-.-........ . ------ Water Supply: Public System and name--- -------------ale-ell. ----- --- --------------------------------.........-......---------------------... ..--- Private �].-•. Character of soil to a depth of 3 feet: Sand 'S1 1]- C;drN e Peat ❑ sandy'LdafmTX Clay Loam [-1 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 sewer is available?twiivthin 200 feet,[ PACKAGE TREATMENT Liquid Depth h _.. [ZSEPTIC TANK I Capacity, C- ---- � -.TYPe - --- ----- --- --Material....- ' No. Compartments---- .................... , f Distance to nearest: Well-----. --14--------------------------Foundation--------------------------Prop. Line-------.. LEACHING LINE [ No, of Lines...........-...............Length of each line ..... _.'__....______..Total Length............. ..__..__..__.______ ` 'D' Box-.)C......Type Filter Material....................Depth Filter Material................................................................ Distance to nearest: Well----------------------------Foundation--------- ------------------Property Line.........-........------:---------- SEEPAGE PIT [ ] Depth_..._...._.___-Diameter....................Number-------------------------------- Rock Filled ll Yes ❑ No ❑ t. Water Table Depth_------------------ ---- - _.Rock Size -- ---- ---------------- - -- Distance to nearest: Well................... ..................Foundation---- ---....-_........... Prop, Line---- - --_. --------------�s REPAIR/ADDITION (Prev. Sanitation Permit#__--------- -------------- ------ .-----.--Date.--.-....---.-.------_-------.------.-----.-_] L Septic Tank (Specify Requirements)_----- -------- ----------------------- ..................... ----------- - - --- ----=----------------------------- Disposal Field (Specify Requirements)----------------- --- ---------------------------------- . .................. ------------------------- --------------------------- ---------------------------------- ................ --------- ------ --- ............._ ...... ......................................... ----------- . -- [Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will he 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, I shall not employ any person in such manner as to becorr}e—su ct to km5 n la' of California." 17 Signed... �� w t. Z �!` Owner BY ---- --- ----- ----- - 7 Title --- --- d frli�'�f1_'_f5 '-....... �- ` (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED - - -2- -DATE .... "" ... DIVISION OF LAND NUMBER.. .... .............. ------------ ------------- -------------- DATE...... --------------------------- - ---- -- - ........... E ADDITIONAL COMMENTS............. ........ ..............------------------------------------------ --_------- --------.._... ..........------------- ........ ------------------------ ------------------------------------ - - - ------- ------- --------------------- ---------- - -- ................... ............... .................... ---- - ----- - ---------------- --- ----- - --------- " - .... . .............. ...--. -- . . ......- ----------- ----- ------------------------------------ ------ - . -- ....... Final Inspection by:....... Date ----------------------------- ........... ------ - I` F&5 21677 REV. 7176 3M EH r3 sa SAN JOAQUIN LOCAL HEALTH DISTRICT. PLATE 24