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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.- ---��` ------------ - (Complete in Triplicate) __.-__ Date Issued____"Z "7- - 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: � i J�G�--'--- CENSUS TRACT - - - ------ JOB - JOB ADDRESS/LO ATION--- �� -- --------- Name___ GS4 t3 . lt�-rcuf--- ---' �Lr,�--- -- Phone - - Address �' f tom. City Zip -` - -- ------- ------ _ -� -- Phone---------------------------------0 Contractor's Name._______ - �'------ - - �-=----- - - _License #'---�- ---- Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ '�(� II Motel ❑ Other----------------- --- -----..--------------- Number of living units:------/--______Number of bed rooms_._.-._Garbage Grinder------------Lot Size------.__.--------------------------------- -------------- ------ _____________Private Water Supply: Public System and name-------- __ -- ------ ---------"--------------------------- - - " ------ ----- - -------- ------ Character of soil to a depth of 3 feet: Sand ❑ Alilt❑ Clay ❑ Peat❑ 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 age pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK (; Size �`� -----------------Liquid Depth____ __________-__ _ Capacity---[4-®Q-------Type -- -v,�--Material__ C , ,-- -No. Compartments - - Qistancetaneurest: WeU__ arc.. '= Foundation-------t a- - Prop. Line---- ' S" '--------- It LEACHING LINE [r] No. of Lines_____:--------------- Length of each line._.____ _a^ -------Zotat Length.,_ _- - -- --- ----- De th Filter Material t �_.� --=- -- ----- ----- 'D' Box ._____-_Type Filter Material------_-- p - f`_Foundation____ __}_ _- � Line - _.Pro e,�ty Distance to nearest:_Well,_-�-C�fi-�.-� , , --'--- P "____Number_____.___-- Rock Filled Yes'( No❑ SEEPAGE PIT [ Depth__ S_�Diameter__:,�f-- - 0r , Water Table VeptV�-----------��'�- - ---------------------- Rock Size---- X__ ------ --- -- Distance to nearest: Well----------- - Foundation lt1-- ------Prop. Line �'J` --------- Date--------------------------- ------------------) REPAIR/ADDITION (Prev. Sanitation Permit#------- ------------ - Septic Tank (Specify Requirements)---------------- ------ ---------------------------------------------------------------------------------------------------------------------- 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. Homeowner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed------------ ------------------- Owner ��------------- Title_-'�t?� -- ----=�`-`- ------------------------- ---------------- ---- ------- ---- - ------------------- _________ - - - --------- -- -- - (If other than owner) FOR DEPARTMENT USE ONLY fDATE._------------'Z------------------------------- APPLICATION ACCEPTED BY.______--- -- -- -- ----------------------------------- DIVISIONOF LAND NUMBER-- - --- ----------- ------------------------------------------------------------------------------ ----------- ----------DATE---------------------------------------------- ADDITIONAL COMMENTS----------- - ----- ------------------------------•------------------------------- ----------------------------------------------------------------------------------. -------------- ------------------------------------------ ----------------------------- --------------------------------------------------- ------------------------------------------- -�------------------------ - -- - -- ' � ----------------- ---- --- ---------------------------------------------------------------------------- -----�- ----------------------- Date ---- Final Inspection b = --------- F&s 21677 REV. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT