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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- (Complete in Triplicate) Permit No-.--�- --------- ------------------------------------- -- Date Issue ------------------- --------------------------+_------------ 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: I JOB ADDF RE : + = } CENSUS TRACT.- ! - ' Phone ne - -- Owner's Name City Address--- .. •ty ------------------------------, Zip. _ _� . --- Contractor's Name--..-- - . License #--3?- � Phone_ Installation will.serve: µ Residence [G]! Apartment House E] Commercial [] Trailer Court,E] :.. ..�.,.....`-.-.- her.-- .._- __-=-- - -- ----- Y. .. ° � •Motel 0- � Other.- i ] . . •-. .;.� F--� ��__ Number of living units:__ -. __-__--Number of bedrooms-.- ._-Garbage Grinder___ - Lot,.Size S.. 5� c�J- ---- i t : ..`._. - k _-,:-F.----.-------- . -- - e --Private Water Supply: Public System andname----=------' - ---: -` ------ ' `-----.---------� Character � of soil. to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat D _ Sandy Loam ❑ Clay Lodm ❑ ' Hardpan Adobe❑ Fill Material__.._. -if yes,type-_-I------'--_--_=- g (Plot plan, showing size of lot, location of system in relation to'wells, buildings,'etc.`:.must be Splaced on reverse side.) �... a... _ NEW INSTALLATION: (No:septic farnk"or seepage pit permifited if public sewer is available with in 2070 feet,] PACKAGE TREATMENT '[ ]"=SEPTIC TANK '[''" " Size / �_:'}j� _`- : :-- ---- ---Liquid Depth- -- Capacity��_p -_ Type Matenal "�N Compartments- _______ ___ � • 1 . ,. e :. Distance to.nearest: W' -6 --------- Foundation_--_,1c --om a`t Prop. Line__- --:-- . No. of Lines.' ---.Len Length of each_line.--�----- _'.Total Length, `;1. ---------- ------- LINE --. --- .-- LEACHING LINT= [ - - g ' ' r [' 'D' Box_ ----..-Type Filter Material:___" __--_.Depth Filter Material ____/_�-.-- 1----------------- _ f Foundation-_ /Q Proper Line .S-. 4 Distance to nearest: Well ---- a------------- - tY SEEPAGE PIT [ De th_ r ----Number ------ _ -- = Rock Filled Yes [�No ❑ ... .. Water Table.Depth---=-------� C-----=------ Rock Size.: --1� w - . ----.. Distanceao nearest: Wei 17--.- :___ ,Foundation �` Prop, kine. $_ _" REPAIR/ADDITION (Prev' Sanitation Per #--"--:_-- --------------------------------------._. a D to ; Septic Tank (Specify Requirements)------,-- = __ = - ------------------ = ------ --------------- -- -- -------------- - ------ ---- = -------- Disposal (Field (Specify Requirements) -------------- ------ ----------- - --. --- - =----- ---- ,----- ----------------------------- ----#- ---- --------•---:---- ---- ---- - ------------- s (Draw existing and required'addition on reverse side] I hereby certify.that I have-prepared.this,application and that'ahe'work-will, -be—done- :in 4ccordance 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: _ f "I certify that in the perfo-rniarice-of'fhe'work for'which this permit-•is issued,-1 shall' not employ any person in'such manner as to becom.e..subf ct to Workman's Compensation- laws of California.',' _ - ! •• '- t i c _ iSigna ed--.------------------ - --I-------- . Ovner-- f T' e ------ -- --------- � (If other'than'oviiner] e :FOR DEPARTMENT USE ONLY t _ ------ APPLICATION ACCEPTED BY.----- -- ---- - DATE -_ DIVISION OF LAND NUMBER.--- ------- - ------------ --------=-- ---- ---=---.-_--------------------------- : �------ . . ---- ----------- -.--:- ------ - ADDITIONALCOMMENTS--------------------------------------- --- ---------'------ --------------------------=------'.---------------- - .------_- --- --------------- ------------------- ---------- ----- -------- a .- -------- --- •------ --------------------------------------- --------------------- Ii ---- --------------- ---- --------------------=----------------------------------- ------------ =------------------------ --.--------=----- - ------------------ ------------------ ---------------- ------- ` -----------'� Date-- ------------ �f Final Inspection by:.---- _ .� = =----- -----` ---"`.: " ----- / F85 21577 REV. 7/76 3M EH 13 24 / SAN JOAQUIN LOCAL HEALTH DISTRICT