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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: --------------- - -- (Complete in Triplicate) 4 Permit No._____-__. ------------- This Permit Expires 1 Year From Date Issued - Date Issued-Vie Application is hereby madeto the San Joaquin Local Health District for a permit to construct and install t he work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Re ulati 4 JOB ADDRESS/LOCATION__ �, O g ons: - - - ------- -- Owner's Name__"____/Z ---------------- -- -------- ------------------------------------CENSUS TRACT - -_ Address - -- ------------Phone - S tet•_ ------------- -- -------- - -- - --- Cit Contractor's Name---- Y-- - ---------------------Zip- ------------------------------ Installation will serve: --- - ---------�---------------"-""-- --- License #___-_--_ --_ � Residence Court Phone___7______ Apartment House --- ------- otel Commercial ❑ Trailer Court (] Number of living units:________ ❑ Other_____.______- _ _ _: - - ---------- umber of bedrooms_________-Garbage Grinds�r_-______-_Lot Size_____--_____--- Water Supply: Public System and name__ _ Character of soil to a depth of 3 feet: Sand ------- ------------ - - - - - EJ - - - - - - --------------- - ----------------------Private ❑ ---------------- - p El Adobe Silt E] Clay E] Peat E] Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Fill Material_... --If yes, type----- -- (Plot plan, showing size"of lot, location of system in relation to wells, buildings, etc. must be placed on r NEW INSTALLATION: (No septic tank or seepage reverse side.) PACKAGE TREATMENT pit permitted if public sewer is available within 200 feet,) [ l SEPTIC TANK [ � Capacity------- ------- -----TYpe_---------- -- Size-----------------------------------------------------------Liquid Depth--------------------------- Distance to nearest: Well -- -------Material-------------------------- _.-- Material No. Co mpartments___---- ---------_---_-_-_LEACHING LINENo. of Lines _---- ------------------Foundation--------------------------Prop. Line -------------------- 'D' Box_ T Length of each line..----------------------------- -------- Total Length _ _ ------------------------------- ------- ype Filter Material____________________Depth Filter Material________-______-__ _ Distance to nearest: WeIL ___--__- Foundation----------------------------Property Line ________ ------------ SEEP PIT [ l Depth____-__ . ------Diameter-- ---------------Number---- -------------------- -- ---------- LA Water Table Depth--------------- ------ -------------------------- Rock Filled Yes ❑ No Rock Size -------------- ❑ Distance to nearest: Well-- ------------------------- _�.------------------- --------------Foundation-------------------------Prop. Line----------- - PAIR/ADQITION (Prev. Sanitation Permit#_______ ____ ___ _ ______ _ ___ ---- Septic Tank (Specify Requirements)------ Disposal Field(Specify Requirements - -- -- ---- -- -------------------- _ _ ------- -------------- (Draw existing and required addition on reverse sid-e) - ------------ - --------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ►rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents gnature certifies the following: I certify that in the performance of the work for which this permit is issued, I shall not employ an become subject to Work an's, om pensati laws of California." Y Y person in such manner as gned -- 40 - -- ------ -- - ----------------- --------------Owner - If other than owner-- ) - ------------------ --------------------Title----------- ------------------------------- - ( FOR DEPARTMENT USE ONLY 'PLICATION ACCEPTED BY VISION OF LAND NUMBER---------------------- __ _DATE.7�'_J 1� ---------------------------------------------------------------- -- �DITIONAL COMMENTS_------ ------------------------------------- --- - - ----------------- -- ---------- DATE ----- --- -------------------- ---------------------------------------- --------------------------------------------- ------------------------ 1I Inspection b - _________________________ ----=------- - --------------------------- ------ - - -------- 3 24 - - - ------------- - - -----------------------------------------------Date ----1-a- - -�� -- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 77 F&5 21677 REV. 7176 3M