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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT p rr :...... JSP . ........ {Complete in Triplicate} Permit No._.. ....`....:........ ------------------- --------------- ------- ---- , i Date Issued... . .. .............................-...__ .............i' 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/LOCATION.............. CENSUS TRACT------- �i ---� --.. Owner's Name.. _Phone -- ------------------- - -- 1/ t � .... .. ........................................ Address----- d -------- City ---------- --------------"--- Zip = Contractor's Name...... ---License #"" Phone.... ...- -- - � .............. � / . Installation will serve: ResidenceI Apartment House ❑ Commercial E] Trailer Court El Mo el ❑ Other ----------------- ---------------- :. Number of living units:......./------Number of bedrooms.....�..Garbage Grinder------------Lot Size_---- A e.................... ........ r Water Supply: Public System and name----------------------- r- --------------------------------------------------------- ' ------_Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ TM Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material . ._._ If yes, type... -------"... f (Plot plan, showing size of lot, location of system in relation to wells, buildings c. must be placed o reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit permitt bli wer is ov ilable in 200 feet,) . _3-_ PACKAGE TREATMENT [ } SEPTIC TANK [ ] Size. - -----._Liquid Depth--------- ............... Capacity------------- -------Type.......... ....M erial --- d-------•-- Compartments__----............................. Distance to nearest: Wel . ... ....... ......... Foun -_.--..".Prop, Line_.---------.---------.-.-� LEACHING LINE [ ] No. of Lines..................... ... en of h ----------.------ ------..-.Total Length _....------•- --- --....--------... �, r 'D' BOX'... .Type Filter at 'al. .. . --_.. _ epter Material------------------ ----------------........ 1 Distance to nearest. Well..- ----------- ou a ion............................Property Line....-----.-.--.--._. ---- Rock Filled Yes No SEEPAGC PIT [ ] Depth................Diame .- ----.-�/.. umbe� ------------------------- ❑ ❑ Water Table Depth-------•-------- - ---------- /----------------- Rock Size.. .................................. .......... L Distance to nearest: Well-----------------------..........-.........Foundation --------.----.--.Prop. Line------------ -------- _--- REPAIR/ADDITION (Prev. Sanitation Permit#................. --_.------ -------- .------Dote.+-!' Z. ..�- -- ) Septic Tank (Specify Requirements)........ -- -.r......-.-.-.. -.....1----- Disposal Field (Specify Requirements) ...... --- .-------.--..-- --- ---- --------- ----------------------- -- -- X _ I ---- -------------------------- ---------- --- .---...-------------- .------- - i - --- ------ l (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 Mules 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 Compensation laws of California." Signed------ . --Owner By................ . Lt ` ...Title ---: --......--- . ------. ---...... ---- ------------- ...... If of er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTER BY---- .......DATE .. 3-. . ............................... DIVISION OF LAND NUMBS --.._ - ----- -------------- -- .....DATE -----------"----- :..._........._.. ADDITIONAL COMMENTS -•-_ - - ------------- -------------------------------------- ------------------------------------------------------------------ ------------ ---.. 0 114u�#Aaol...............................- -- --------------------------- ----------i----------- .......----- -.--- ..... -- -------------------------------------- ------ ------------------ --------------------------------- -- --------- ---------- ------- - ------•-- --------- .......... -•...... ------- - ---------------... ----- ---------------------............................• ..... -------- --------- --.•--•-------------- ---- -------------------- FinalInspeciion by:------------ ------------ --- ---- -- -------...------•---------------------------- --Date...----------- -------------- --------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7/76 3M