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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 2_ --------------- 0 & _ ------------ ___ _ ___ (Complete in Triplicate) Permit o.-__ ___ Date Issued__O �/ _=_7;2 ----------_----_____-_-_____---------------------------- This Permit Expires t 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----------- � �__;___ .Q _ CENSUS TRACT_____ _________ ______________ Owner's Name---- -- ----------------------------------------- - Phone----------------------------- ------ Address -� '3 -------------- ------ -------- ----- -------------------------------------City ----------------Zip----------------------------- ------ ---- Contractor's Name____` ___ __--'_�- -- '-- -- - ----------------- --------------------License #_2_ 7hS �f ------Phone- /(........ Installation will serve Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel-❑ Other ---- , Number of living units:___: ______Number of bedroomsJ__��_----Garbage Grinder___-______Lot Size___, '_� 1----______________________,_____ Water Supply: �ublic System and name----: ---_ _ _C% -----4 ------Private❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Ciay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe R' 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.) ` I NEW INSTALLATION: (No septic-tank or seepage pit permitted'if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size____________________a___._______.____________--------Liquid Depth.-------------------------- Capacity--. __________________ Ca acit ___ ----- Type Material _ No. Compartments ______ Distance to nearest: Well___ _ ___- _ __ ______________Foundation--------------------------Prop. Line_ ____ LEACHING LINE- [ J No. of Line., _ ..______-.__ --------Len-gth of-each line-------____________—____.Total. —_ 'D' Box___________Type Filter Material--------------------Depth Filter Material----------------------------------------._____-_______________ Distance to nearest: Well________________.__-_____Foundation,-______ Property Line ______________ SEEPAGE PIT [ ] Depth---______-------Diameter-______-_______Number-------------------------------- Rock Filled Yes ❑ No WaterTable Depth-------------------- ------------------------------------Rock Size------------------------------------------------ t Distance to nearest: Well_________________________________________Foundation-__-_________________-Prop. Line_-_____________________. REPAIR/ADDITION (Prev. Sanitation Permit#______________________-__________________-Date_____________________________________-__-___) Septic Tank (Specify Requirements)-------------------------- ---------------------- - -- ---- ---------------------------------------------------------t------------ Disposal Field(Specify Requirements)------- -------3,-- - - d9 ! --------------------------------------------------------------- -- ---------------------------------------------------------- --------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner at to becometo kman' pensation laws of California." L-®�-fx---- Signed-----� --------- --- ,-- --- Owner BY------ ---------------- Title--- �' f -------------------------------------- k ---------- (If other t aOwner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ � r DATE.--- - -� �-------------------- DIVISION OF LAND NUMBER. - ----------- --------------------- -----------------------------DATE-------------------------------- ------ ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------ ---------- --------------------------- -------- ------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------- ------- ------------------------------------------------ -------------------------------- / 5 Final Inspection by:------ -- ------------ -- -- Date---- 1-__ v - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FIS 2167. 7/76 3M