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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------------------- . (Complete in Triplicate) Permit No._7___-/C�O -------------------- _ 1'� Date Issued_ -�� - .� ----------------- - ---------- ----- ------ 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/LOCATIO 5156//-& L- _- --_______CENSUS TRACT___________ -------------- Owner's Name------- --- ` W_' ` ----------- - -- -- ----"----------------- - -----Phone--- Address----- -Address----- Z - _ Cy--- i -----------zipb- Contractor's Name_____________ _ ______ --- _________ -___ -- �� - Phon--------------- _ e "76 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ElOther-- --------------- ----- -- -- ---- ----- f Number of living units: Number of bedrooms----�-_Garbage Grinder------------Lot Size-------- _/ tt AA� Water Supply: Public System and name------------------------------------------------------------- ----------------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 lot, 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 _______Liquid Depth ________________________ [ ] Size------------------------------------------------ Capacity---------------------Type---- ----------------Material---------------------- --No. Compartments----------------------------------- Distance to nearest: Well_______________ ______-____-Foundation-_____________________Prop. Line------------ --------------- LEACHING LINE [ ] No. of Lines---------------------------- Length of each line------------------------------Total Length ----------------------- - 'D' Box------------Type Filter Material _______Depth Filter Material--------------------- -----------------------___________-____- l Distance to nearest: Well----------------------------Foundation_ --------------------------Property Line-------------- _ ______________-. SEEPAGE PIT ( ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth--------------- ----------------------------------------Rock Size - Distance to nearest: Well-_.__-___________-____________-_______Foundation------------------------- Line__________________________ REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date Septic Tank (Specify Requirements)-------------------------- __ y Iv�'c"'�`' Disposal Field (Specify Requirements)_________-_�____ _ __________ _ ___ X--)-� -------- ---------------- -------------- -------------------------------------------- -- - ----------- ------ ---r-------- ---- - - -- - ------------------------------------------------------ ------------------------------ - --------------- -------------- - (Dravy 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---------- ------------------------------------------------ fother than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ /�' ------------------------- DATE _t __�_f=° - '" - ---------------------- DIVISIONOF LAND NUMBER. --- ---------------------------------------------------------------------------------------DATE---------------------------------------- ------ ADDITIONAL COMMENTS ----------------------------------- --- - - ----- ---------------------------------------------------------------------------- ------------------------------- ------------------------ ---------------------------------------------------- -- -------------------------------------------------- --------------------------------- FinalInspection by:------- ------ ------ --- ------------------------------------------------------------------------------------------Date ----/x ----�6 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M