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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.___ ___-._ This Permit Expires 1 Year From Date Issued 7 (Complete in Triplicate) 7 --� -� 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----J-J;_e ---- 11 x ------------------.CENSUS TRACT-------------------------------- Owner's Nome-------C� \Phone-- --- ----------------------------- Address ---- --------- -------- --- - ---- - ---- - Address--------- ----- ---------City--- ---- _ - -------- f-------------------Zip--------------------------- Contractor's Name----[- -- _ -- �'-__-- _ -_- License #_5`' _{_�_ - Phone---------------------------------- Installation will serve: Residence Apartment House.❑ Commercial ❑ . Trailer Court ❑ MotelE] Other---------------------------------------------- Number of living units:-----t-------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 E] Clay ❑ Peat E] Sandy Loam Clay Loam Hardpan ❑ Adobe ❑ Fill Material_---------If yes, type-------------------------------- (Plot ___ -(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 see ge pit permitted 'f public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC' [ Siz _�__ Liquid Depth. -- Capacity__, Q_C-______Type ______ _Material_.A�_Zt_e,_____No. Compartments-------' --_ -__A__________. / Distance to nearest: Well-----------_4-6---------------------------Foundation______to_________-_Prop. Line______ _-_________ LEACHING LINE [ JI" No. of Lines----------j _______________Length of each line �� --------Total Length `h_ _--___�__�___(___C_l__`___ _ ___________- ___________D' Box____ _.-_.Type Filter Material___.C_ ______Depth Filter Material l __t �Distance to nearest: Well_______„SZ_l_________Foundation__-__1d_1_________Property ----------------------- - Depth__ ry_/_X16r_Number_.-----------)------------------- Rock Filled Yes [�No ? iP Water Table Depth--------- - -----------------------------Rock Size-- f -9----�--3------------------------ --- ------------ ------- _ Distance to nearest: Well.-------- 17_/��_____________-_- Foundation_____lD ____.Prop. Line_____`__/ - -------REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------- __..:_: -33ats- _____ __________) Septic Tank (Specify Requirements)---------------- ---------------------- _ - --------------------..r—4--------------------------------------------------- rw�. Disposal Field(Specify Requirements)_.___-._,,. __,________.__-____--__-__________________________- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------- ----------------------------------- ---- ------ ------------- (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 mpensation laws of California." Signed--------------------------------- --- -- ----- --------------- -----Owner ------Title-- ------------------------------------------------ (If other than owner) R PARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ---- ------- ----------------------------------------------DATE_- - ? ---------- DIVISION OF LAND NUMBER---------------- ------------DATE--------------------------------------- ADDITIONALCOMMENTS-------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- -------------------------------- ----------- --- '-- - ----------- ----------------------------------------------- - - - -- Final Inspection b __ �' P Y �. - . .. I:..�- -----------------------------------------------------------:-- ----------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M