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FOR OFFICE USE: FOR OFFICE USE: s APPLICATION FOR SANITATION PERMIT ` Permit No..:- 4..=. ------------- ------------------------------------------- (Complete in Triplicate) p ---------- ------------- ----------- -- Date Issued._:-�y:_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. 544 and existing Rules and Regulations: CENSUS TRACT------------- ----------- ------ JOB ADDRESS/LOCATION-1-2... Phone---- ----------- -- ----------- ------ Owner's Name------- - - A-t ---- ----------Ci `' " "'-.-------------- --------Zip------- ------------------- Address.-- --------- city Contractor s Name------- ,-�- - ------- License # �.. Phone---- -------------- -------------- Contractor's ---- Installation will serve: Residence e Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------ Number of living units:.___.r-----.---Number of bedrooms----- _Garbage Grinder_----------Lot Size----------------------------- --- Water Supply: Public System and name----------------- -- --------------------------------------------------------------- - Private 0"'r Character of soil to a depth of 3 feet:/Sand ❑ Silt ElClay ElPeat 71Sandy Loam E] Clay Loam ❑ Hardpan E 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 within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------- ------------- -------~ Liquid Depth.-.------------------ ---- Capacity---------------------Type------------ - -----.-Material--------------------------No. Compartments----------------- Distance to nearest: Well--------------------------- ------------;Foundation--------------------------Prop. Line--------------------- ----- LEACHING LINE [ ] No. of Lines-----------------------------Length of each line----------------------------=-.Total Length.--------------------------------------- 'D' Box------------Type Filter Material--------------------Depth Filter Material-------------------.------------------------- ------- ----- Distance,to nearest: Well----------------------_---Foundation.---------------------------Property Line----------------------------------- SEEPAGE PIT [ ] Depth_--------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No WaterTable Depth--------- --------------------- -------------------:----.Rock Size------------------------------------------------ Distance to nearest: Well----------------------=--------------------Foundation_---------------------- Prop. Line---------- ----------------- REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date------------`---------------------------------} Septic Tank (Specify Requirements)------------------ -------- ------------------ ----------------------------- ----------------------�----------------------------- _------- P Z`.".'�------------------------------------ Disposal Field {Specify Requirements).:.___��-��----- �- - -- - 1 - "x - - ------- --- ------------------------------------------------------------------------------------ - ---------------------------------------- ---- -------- _.. (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 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 its 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 CompensaWtian of .California." Signed-------------------------------- -------- ------ ---------- --- ------ Owner By --------------------------- --------------- -- ----- - ---- Title- --"------------------ ------ ------------------ (If other than owner) FOR DEPARTMENT USE ONLY �y7 DATE ---- APPLICATION ACCEPTED BY---..-- _-- "/F DIVISION OF LAND NUMBER ---------- ----------- ----------- ------------- -------- - --------------- ----------- ----DATE.--------- ------------- ------------ ---------- ---------------------------------- ADDITIONAL COMMENTS------ --------------- - ---------------------------------- --------------------------------------------------------------------------------------------------------- ------------------------ -------- -- Date Final Inspection b FV 7/76 3M L) .-- -- B.S 21677 RE EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT