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F6P<-_.OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- -- ------------ Permit No-7.�_-_�� (Complete in Triplicate) --------------------------- - -- - ---------------- Date Issued__5"_1 -�" 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: JOB ADDRESS/LOCATION / iJ_ls -- - -_��-__ ------/------------------------------------------ CENSUS TRACT Owner's Name--- - ---- - - --- ----------------- -_.-.-- - Phone------------------------ -------- Address-.--- -- -- � ----�� -- - '-"--=--- �-1-- } City - ZiP � ----- --- ---- ..- ---- _ Contractor's Name ( � --------- ----------- - License #_c�--/S'34 Phone _ _,S.:aC/6� Installation will serve: Residence❑ Apartment House.E6Com ercial E] Trailer Court E]Motel ❑ Other--_-__ ------ -_ . Number of living units:----------------Number of bedroom&---_-_----___G�arbag Grinder___________Lot Size__'-,0_ U___-_______._______________ Water Supply: Public System and name------------------ -L u-�C---IyU/GL -------------------------------------------------- -----------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material-_---------If yes,type-------------------------------- (Plot plan, showing size of loth location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth--------------------------- Capacity_-------------------Type-----------------------Material--------------------------No. _ -_-------Capacity-------------------TYPe---------------------_Material--------------------------No. Compartments----------------------------------%e Distance to nearest: Well _________________-------------------------Foundation--------------------------Prop. Line---------------------------- LEACHING ____-______. --_.LEACHING LINE [ ] No. of Lines_------___------------------Length of each line__.._.________________-____.Total Length ______________ ----------------------- 'D' Box_______.---Type Filter Material___________________Depth Filter Material___--__-__--_---__.___-__--____-_______-____._-_____-- I Distance to nearest: Well ._-.:_-------------------Foundation___-.-___`-__--_--____---Property Line---------------------------------- SEEPAGE PIT ( ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance to nearest: Well_-----------------.--------_-------------Foundation--------------------------Prop. Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#_______________________________________.________-Date__-___.______---------------------------- -) Septic Tank (Specify Requirements)____________ ____ ________________ __ . __.___'f____._ _._ __ __ __ ______________'____ ____________._ ___,-_-_____. 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 ub[ect to Wor magi s Compens tion laws f California." l , Signed ---- -- -' --,- C --------Owner BY------ --- --------------- ----- .Title--- - - --- - - ---- - --� - t -------------=------ -------------------------- ------------------------------- If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------ ----------------------- ------------------------------------------DATE --- 3 7 ---- DIVISION OF LAND NUMBER.---------------- -------------------------------- ---------------------------------------- -----------.DATE---- - ---- ADDITIONAL COMMENTS __ _--- -- . --__ _--. ------ - ___ . -__. - -- --- --- ----- --- -- - - --- --- - -- -- --- --- - ---------- ------ - ------------------------------------ ,{� -- ------------------------------------------------------------------------------------------------------- - ---------- Final Inspection by:-----0--- - - -- '� ----------------------------------------------------------------Date-----------j' 7 e" is sa SAN JOAQUIN LOCAL HEALTH DISTRICT Fas elan eey-7L76 3M