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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ G a� ---- ------------------------------------------------- -- (Complete in Triplicate) Permit No.._ --------------------------------------------------------- Date Issued---?",z F77 _------------------- This Permit Expires I 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 Regul tions: 3-1G1 ?� " f�q2f � flr cv,�Y gg JOB ADDRESS/LOCATION,_S ,�{I -'^ w .Sl _lf� !�r{----- `�` ...__.CENSUS TRACT Owner's Name--- -------- ---------------- ---------------------------- .- ---------- --Phone--------------- -------------------- ----Zip �` - -- ----------- ---------------------------- ------------ City--Com"-v~;�c-------------V- ------- Z'P _,. '-e , License #_- .ffZ�z G__Phone------------------ - ---------- Contractor's Name___ 4��, - .-�--- ---------------- - Installation will serve: Residence ❑ -Apartment House Commercial Trailer Court ❑ Motel ❑ Other--------------- ------------ ------ Number of living units:----------------Number of bedrooms--- ----Garbage Grinder_._____,._,_Lot Size.-_____-__.._ ------------------------------- Water Supply: Public System and name-_._-'_--------------_ ____ - Private ------------------------------------- 4 Character of soil to a depth of 3 feet. Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam }] Clay Loam ❑ Hardpan Adobe ❑ ' Fill Material_-_---------If yes,type_-____^______.__------------- �L (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,) r' �__--x��'r -------- Liquid Depth " PACKAGE TREATMENT [ ] SEPTIC TANK [y] Size- -- Ca acct d---------Type��r-Material__--_ a -_---•--No. Compartments---- ------- ,/----------- ---------Foundation-?._40 -------------Pro Line_---- -------------- -- Distance to nearest: Well. /Q� ------___ - �/ P' -------------- Length of each line.-------- -T-otal Lc-.gth.__ Line--- LEACHING LINE [ No. of Lines-________ -------- �r 'D' Box-----1-----Type Filter Material----.�_ ----.Depth Filter Material----- ----------------------------------------- Distance, ------------------------- ------------Distance to nearest: Well- ___lee Foundation-_____ --__--Property Line - -- ----- -- Rock Filled Yes WNo SEEPAGE PIT [ Jl� Depth._ Diameter___/ -- Number-------- --------,'--- e d Rack Size._ ,rte------------- --------- Water Table Depth-------- f� / Distance to nearest:. Well---.____� 'a ----------� �Foundotian- ----Prop. Line---- REPAIR/ADDITION {Prev. Sanitation Permit#--------------------------------------------------.Date___.___.__--.-_---_`--------------------- -1 -- --------------------- Septic Tank (Specify Requirements)------- ------ -- --- --� ---------------- -------------------�----- ------ - --------------------------------------------- Disposal Field (Specify Requirements).__---.__.._----------- ----------------------------------------------- -- ---------------------------------- ----------- ------ ------ -- �f y N . _____________________________z___---_.____-_.__.-----______-_.____-_____.______-___ - --- --------------------------------------------------------- (Draw existi ng 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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: '` 111 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 pensation laws of California." Signed------ ---------------- -------1------ ------ ----------------- ....... ------Owner Title- ------------------- -------------------------- By---------------------------------------------- (if other than owner) «r' FOR.DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -----' ►----- -- ----------------------------------- DIVISION OF - , .. DIVISION OF LAND NUMBER----------------------- --- - ---._-DATE------ ---- ---- ADDITIONAL COMMENTS-------------='---------- -------------- ------------------ - -------------------------------------------------------- ------ -------------------------------------------------------------------- - -------------------------------- ----------------- - ----- -- ------ --------------------------------- ------------------------------------------------ ------------------ Final Inspection b - ----------------------- ---------------------- ------ - - -- - i -_-----Date --_ - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/7t