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FOR OFFICE USE. v FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- Permit No._2g%7/4_$-_y (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 com�p+liance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION___ _-! -____ ► -- / ___- - f CENSUS TRACT r Owner's Name_1;1;< a--- - _.I_Al � �h� -------------------- Address--- Phone - ?'/x ------- --- ---------------- y� 7- Address -'f`�� tom'6 -- �- �Q�.-- -,r� ----------- ---- City y /'! i / '�1 Zip '��P ----------- -------------------- _ �` _/j'�' _ � Contractor's Name_ �-3@ ----- --:- -- --------- ---- --------License #�_��-'�f--�-� ----- Phone--I /�_'��_"- ------- 7-- -- Installation will serve; � Residencer�Ap rtment House% Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ------------------------ ------- - --- / y1 Number of living units:----1________Number of bedrooms.__.% Garbage Grinder-----_------Lot Size-----�Ui'.�_._/7L'--------------------------------- ._ 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-C] 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 fd� ] Size---- ---- ------- --------------------------------------Liquid Depth.-------- -------% Capacity/.Z --_-._--Type-----------------------Material__�/� ��__No. Compartments---- ----------- ----- a --------- r � Distance to nearest; Well.___/�O _1---------------------Foundation---lZ__ Prop. Line______________------- -- LEACHING LINE [ ] No. of Lines._.___ __ ____.___ t -____--.Length of each line.-----�.Q�_�y-.__._--.--.Total Length._�4�'OQ_ -_,r-_--________----- f 'D' Box---I-------Type Filter Material t/ i -------Depth Filter Material---IT--------_------------------------------- ----------------- , Distance to nearest: Well---� 'Q_�- y - - ---- --Foundation.-'�--,'�- --------Property Line--------------- ------------------- SEEPAGE PIT [ ] Depth._A2I----Diameter_.._.3_(P--'---Number---------/------------ -------- Rock Filled Yes X No❑ Water Table Depth---------------------- --- --------------------------------------------- -- ----------------Rock Size--//-��------------; f -- ------------- Distance to nearest; Well------�8©___�______--------------Foundation_.__. ______-------- Prop., Line------------------ _______-. REPAIR/ADDITION (Prev. Sanitation Permit#______________________---_ ---------------------Date----------------------__ Septic Tank (Specify Requirements)_---------------------------------------------------------------- ----------------------------------- --------------------------------- Disposal -------------Disposal Field (Specify Requirements)------- ---- --------- ----------------- ----------------------------------------------- ---------------- -------------------------------------------- --------------- --------- -------------------------------- ------------ --------,------------------------------------------------------------------------------ --------•------------------------------- ------ _�----------------------------------- - ______________________________________ i (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that theL work will be'done in`accordance'witTi_.San Joaquin County F Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "1 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 1 beedcome ubiect to W7- By an Compensation laws of California." g - --- ------ ----- - ---- ----- ---- - -----..__4----------------------------- --------------------------------------------------------------------- - - Title--- --------------------------- ---------- --- ------------------------------ ---------- (If other than owner) r 1 '. FO EPART E T USE ONLY APPLICATION ACCEPTED BY------. - --- -- - --- ----- ----- ---- ------------------------DATE-------1 --- -------- --- DIVISION OF LAND NUMBER.------------- --- - ' �` -------.DATE.------------------- ADDITIONAL COMMENTS. --- -----------------''--------------------------- ---- ------------------------------------ ---------------------------- ____________________________________________ __ _ _ ______----____ ----------------------------------------------- --------------- ----------------.------------------------------------------ -------------------------------------------------- t ; -------------------------------------------------------------------------------------------------------- :., Final Inspection by Date_._ - � EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/7h 3M