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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - � (Complete in Triplicate) Permit No,,.................. ---------------------------------- ---- ------ ---- -- - Date Issued-/a _________________________________________________________ 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 Regulations: 4 JOB ADDRESS/LOCAT N. a- ------_��.-��- - --'--- l�.l��-�,�.� Q --.CENSUS TRACT-------------------------------- Owner's Name----a.6�--- 51Wt2,e_e"- - - --- LPhone--------- -------- ------------ ------ � �Address-- - ---... - CitY x -- ---- - ------ - Contractor's Name----- -------------------------License ____Phone_ Installation will serve: Residence E��Apartment House.❑ Commercial ❑ Trailer Court ❑ / Motel E] Other---------------------------------------------- Number of living units:-------l_______Number of bedrooms--.:?-----Garbage Grinder----Z`___Lot Size------3'o-�ed-`1--.'_________________________________ Water Supply: Public System and name-------------------------------------------------------------------- -----------PrivateZ� 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 200 feet,) Q 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' ______-._-_______-_--__-._______-_ .'D' Box------------Type Filter Material----------_---------Depth Filter Material-------------------------------------------------------------- -------------- Foundation------ ------..Property Line-------------------------- ------- b SEEPAGE PIT [ ] Depth Distance to nearest,.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) ---------- --- --------------------------------------------------------- Disposal Field (Specify Requirements) __________________ ____- ---------------------------------------- --1 --�---�-------.� r ----` - - ----------------------------- ----------- --- ---------------------------------- -- .:, -5 � �' ----------------- (Draw existing and required addition on reverse side] 1 i I hereby certify that I have prepared this application and that the-work will be.done An--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 becomesubject to Work n's Compensation laws of California." Signed- ------ -- ------ - BY 'LJ Title --- C....... -.. ---------------------------3A (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ----------- ---------------------------------DATE.--/-�� DIVISION OF LAND NUMBER ---------------------------- - ---------------- ------ DATE------------------------------------------------ ADDITIONAL COMMENTS------------- --------------- -------------- --- ---------------------- - ---------------- ------- ------------------------------------------------------------ ----------- - ---- -------- - - - - ---------------------- -- --- --- -------- Final Inspection by------------ - - - -- --------- --- Date -- ------ -------------------------------------- - - ----------------- ---- -------- - --------------------------- ------------ EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&S 2]677 REV. 7/76 3M