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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No..Z. =. � ` Date Issued__--?-__ / --------------------------------------------------------- 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/LOCATIO _ -'------ ---..CENSUS TRACT----------------------- --- - U ` Owner's Name. }. .. __ F_ ---- ---- ------------=--:-.----.--.------- R --:----------. Phone Address 1 -----------Cit'- �'- " -----------`--- --------Zip--------------------= Contractor's Name----- __.__._._____. one =_ = =License # Z. Ph Installation.will serve: y Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ a Motel ❑ Other --- y ' ------------------- ----- Number of living units________ _______Number of bedrooms---..Garbage Grinder_.=_:-------Lot Size-------=.z_ --------------:------,_>,_--------------------- Water _.__--_...:__ --___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 ❑ 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 206 feet,) PACKAGE TREATMENT [ '] SEPTIC TANK [ ]' Size r----------------------------------------------------------Liquid Depth ------------- A- • Capacity------' ' =----TYPe---------- - ----.-Material------------- No' Compartments ------- i _.. Distance to nearest: Well ---- --Foundation------------ =-------- -Prop. Line-- LEACHING ine •--� . + # { t N � LEACHING LINE! [ ] No. of Lines------------------ ------ --Length of each line=.-.=- --._-- ......................Total ,Length-------------------------------------------- E), --.------_- ---------:--- - r D BOX------------Type Filter Material---------------------Depth Filter,Material-------------------------------- i is Distance,to nearest: Well ----------------b Foundation-.-_-----'*-------- -_ Property Line------------------------------------QQ `) SEEPAGE PIT [ ] Depth-----------------Diameter n----------------- -..°R= ------------------ Rock Filie<d 'Yes ❑ No ❑ ' t Water Table Depth----------------------------------------„.---- -------.Rack Size - = = ,1 Distance to nearest:Well---------------=------------------------i__Foundation -,----..--------------=..Prop. Line--------_---------------- ---------------- -----------_ REPAIR/ADDITION [Prey. Sanitation Permit#------------------- -------------------------------Date- ---...._:----------_-----_--- ] Septic Tank (Specify Requirements)------ - -------------------------=------ - ---- = L Disp field (S ecify Requirements),_,____e_4-,,,i” ^ti► A. -�i'": * ;a Y ; .. .e ,r 1. �_ `_ - 1''- _ � --- ---- - -- - ------------------ ------------------ - �: _ --------------------------------- --- --= - --------------- [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 Rules 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.". I Signed------- -----=--- ------- _ :Owner i r - ....... .. :..:... ,--_ _ BY - ----- --- -- -ti----- -S"" •----=------) Title- # .. i a- _ — { . (I,f other than owner) F R'DEPARTMENT USE ONLY ? � APPLICATION ACCEPTED; 8Y.°___ _. .. = - ------------------------ DATE'. "- DIVISION OF LAND NUMBER ------- ---- = ---- ------ ----- ........------ - ---------------------------.DATE.-------------- --- ------ -- - . j ADDITIONAL COMMENTS- --------------------------------------------- --------------------------------------------------------:------------------------..-...... ---------- ------- ----------------------------- ---- ----------------------------- : f ------------ -------------------- --- Final Ins action b - ------------------- Date Z� J� ---- ------------- J - EH 13 24 _ SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M