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i FOR OFFICE USE: FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT ------ --------- ------------------------------- fL (Complete .in Triplicate) Permit No._-7-.-y.-- ------------------------------- ---------------- Date Issued-- --------------- ssued__................. --------------_-_--._.-.--.----------------------------------- __ 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: JOB ADDRESS/LOCATION-- - . ------- ----------------- ------ ----- ---------------- CENSUS TRACT-------------------------- - Owner's Name ------ OLA ------ --------- ------- -- -------- -------------------------- --------Phone----- -- -- ------------------------- Address t CityZip - /L - -- r Contractor's Name /1 = ----- License # - Phone. Installation will serve: Residen e 2""Apartment House.❑ Commercial ❑ Trailer Court'❑ Motel E Other --------------- ------------ - --- Number of living units:__:.-�- ---_-Number of bedrooms_-- _Garbage Grinder------------Lot Size----- —-- 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 200 feet,) 90 PACKAGE TREATMENT [ J SEPTIC TANK [ ] f�Size-------- 7 -- ----- ----------------------------------------Liquid Depth.------- ------------- Capacity Type =1------ '------ Material---------- ---------------No. Compartments------------- --------------------- ' Distance to nearest: Well--------------------1 .-- -----------Foundation--------------------------Prop. Line-------------------- -------- LEACHING LINE ( `] No, of Lines-------------------- ------ ----- Length df�each line ---------------------- Total Length. 'D' Box-------- -Type Filter Materiail� -------------Depth Filter Material----------------------------------------------------------_-- G Distance to nearest: Well - Foundation_-----------------------:--Property Line------------------------------------ SEEPAGE __------ ------------- SEEPAGE PIT [ ] Depth----------------Diameter--------- ----------Numb'er-------------------------------- Rock Filled Yes ❑ No ❑S Water Table Depth ; ' . =! ; `------ --- Rock Size �* s .777 1 Distance to nearest':,Well------------ - ----`'moi.----�--------Foundation------------------------ Prop. Line------------ g REPAIR/ADDITION (Prev. Sanitation Perini''t.# "` T =-------------Date______________________-.-_--.------- ---} � 4$ Septic Tank (Specify Requirements)-.._ -- -- -;--` Y" ----------- ---------------------------------- Disposal Field [Specify Requirements]---- --- �.- ---- ------- ------------------------------------------------ - ------- 1 16°-0 - �/"'� �D �� U p-�-- ..---!'-"�p--------------- ` 1 -------- ----------- ----- ------------------------ --- (Draw-existing-rind-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: r � "1 certify that in the performance of:the'work for wh{ich 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- ----------------------- — - Owner ------------ ( �� Title ---- ----------------------------------- (lf other than;owner] , L FOR DEPARTMENT USE ONLY ' ` APPLICATION ACCEPTED BY --- ----------------------==------------------ --- -- DATE - DIVISIONOF LAND NUMBER.---------------------- ---------------------- ---------------------------------------------------------DATE------------------- ----------------=----------- AQQITIONAL COMMENTS ----------------------------------------- -------------------------------- - ---------------------- -------------- ----------------------------------=------------------------------------ --- ----------------------------------- -------------------------------------- ------- - -------- =---------------------------- - _ r� -Date--- -- '�_` - ----------- - - ------------------ Inspection by:.----- <^ - - - - - --------------- Final .EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8S 21677 REV. 7l7d 3M r'