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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - -------=------ ------------------------- (Complete in Triplicate) Permit No----------- ` ----------------------------:-------------------- --- _s 7] - 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/LOC ON.-/D---9_5 - ' dead"----- ----------CENSUS TRACT--------- ----------------------- Owner's Name. . Phone Address------ fJ �tl__ itY-` Zip------------ -- Contractor's Name-- '�� ---------------License Phone Installation will serve: Residence [Apartment House.❑ Commercial ❑ Trailer Court ❑ i � Motel ❑ Other-------- ----------- -- Number of living units-------- -----Number of.bedrooms_-�-_--Garbage Grindw------------Lot Size_-.__._-------------------.--.-- --------_-------------- Water ----- __Water Supply: Public System and name --------------------------------------------------------------- -- P �- ----- ---------- ---------=Private . Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ ' Sandy Loam ;Clay Loam ] Hardpan ❑ Adobe ❑ Fill Material-------------- 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 spit permitted if public sewer is available within 200 feet,] v. PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------------------- --------------- Liquid Depth.-------_-----_-------- __-- -1-4- �- Capacity------=---=----------Type-----------------------Material------ -----------------No- Compartments-------------- r to nearest: Well-------------v- -----------------== ---Foundation.-------- -----------Prop:;Line------ -------------------- LEACHING LINE ] l No. of Lines------------------------ Leng'iWdf'each line.------ ---- --------------.Toa Length ---------------------------------___{-- i D' Box--: Type Filter Material ------: �. 't:' yp p ., -------- Foundation--------------------------- De th F,ilter_Material_5-_ Distance to nearest. Wel! _____ _______ -.P_roperty_Line----_-_-_-_______________________. ... _. .. F. 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 __-_------------ --------------- Septic Tank (Specify Requirements) __________________ ____..____ ------- - Disposal Field (Specify Requirements) J ---- ---- - -- -- -- - .---------------- --------- --- _ u ---- (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 Coun Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent 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. Signed-==--- ---------- ----- ---------'-- - ----- Title _ BY - re - (If other than owner) ' a r t FgR DEP TMENT USE ONLY APPLICATION ACCEPTED. BY-------- % --= I- / -------------------- :_DATE.. Z- DIVISION OF LAND NUMBER-------- ------- ------------ ------------------------- .: DATE ADDITIONALCOMMENTS-------------------- ---------- ------ -------- --------------------------------- ---------------------------- --------------------- ------ --------------------- 1 =--------------- --------------------------------------------------------.--------------------------- -----k------------------------------------- -----------------------------------------------'------------------------------------..-______---..--- ------ ----- -Jf. _---_------------- f - V , Final Inspection b '` J ?-c' - - - - ---------- ---Date--- - P Y = =" ----------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 21b77 REV. 7/76 3M