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FOR OFFICE USE: � �� /� FOR OFFICE USE: - -� APPLICATION FOR SANITATION PERMIT �i E: ------------------- 30-- ------- ----------- Permit Now___'_ Sell �]'l/) (Complete in Triplicate) - --- - a6__ � C-- _._ This Permit Expires 1 Year From Date Issued 4"1/----- ----------- I 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 hCCounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION----------- 7Fe_L----- /----- ---- � 1.Q^ ---------------------------------------CENSUS TRACT-------------------------------- Owner's Name------------------------ --- - - --------------O - ------------------_ Phone___ � � Z Address 5'0 _ --------------ty----------- ---------- - - Zip------------------------------ ------------ Contractor's Name__________ el73 H-----_______-______License #A51-1-93--------Phone-Y� -96_D7______- Installation will serve: Residence❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 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❑ d Sandy Learn ❑ Clay Loam ❑ 0� Hardpan ❑ Adobe ❑ Fill Material---------._-If yes, type`_______-____-__-__ (Plot plana, showing size of lot, location of system in relation_to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tanks' or seepage- pit permitted if public sewer is available-w4hin 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK, [ ] Size----.------------------------------------------------------Liquid Depth--------------------------- Capacity... _-_-_--__-_______________Capacity... -----------------Type------------------- ---Material-------------------------No, Compartments ------------- Distance to nearest: Well--------_----------------------------------Foundation--------___~__`___--------Prop. Line____________-__________--. LEACHING LINE [ ] No. of Lines-----------------------------Length of each line------------------------__ Tg#al Length____________-._____-______________-_- 'D' Box------------Type Filter Material--------------------Depth Filtel Material---------------------------------------------------------------- Distance to jnearesf ell----------------------------Foundations'---------------------------Property Line-----------------------------------. SEEPAGE PIT [ ] Depth----..___ Diameter--------------------NuMber-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth----------------------------------------=---'-----------Rock Size------------------------------------------------ Distance to nearesttWell,____,_,_`y_-._______-e.__.__,,,._ W_-_Foundation----------.---------------Prop. Line__________________________. REPAIR/ADDITION (Prev. Sanitation aPermit#_---..____.-_- ____---___-_.___;Dote._._—_:___7: ___________________) 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. 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 Compensation laws of California." Signed------- ------------------ ---------- - ----------------------------- - - - _Owner By----------- - ---'----- ----------------- -------------Title---------- --------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEP ED BY-------- -,0(----- -----0-3--- --------------------------DATE----51Z(1170--------------------------- DIVISIONOF LAND NUMBER---------------------------------------------------------------------------- ------------------------------DATE--------------------------- -------------------- ADDITIONAL COMMENTS____________ _ ! -__ --------------------- ---------------------------------------------------R,---- _ z ______ -- ---------------------------------------- --- -------- -------------------------------- ----- ------- -- Final Inspection by:.------- - - --- ---- ---------------------------------------------------------------------Date--5.- 31 ? -- EH 13 24F&S 21677 REV. 7/76 3M SAN JOAQUIN LOCAL HEALTH DISTRICT