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FOR OFFICE USE: FOR OFFICE-- - - USE: APPLICATION FOR SANITATION PERMIT ----------- ------------------------- ---------- --- f ----------- - -- (Complete in Triplicate) Permit No.__________________ 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 Rggulatipns: � � I ^ � f `'CENSUS"TRA�CT,-------------------------------- JOB ------- r, - ---JOB ADDRESS/LOCATION FPhone_ t ------------------------------ -r -- --- ------Owner's Name - c�tY - ZlpZ�Address__P--- -- - ------ --- -- -- --------------- ---- #Contractor's Name--------/L,6__'C ___=_ ____-__----License % J- --Phone ,!V �___- ------6. Installation will serve: Residence N_ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------------------------------- ----- Number of living units:-_-r -------Number of bed rooms..`_d_'_Garbage Grinder------------Lot Size-- -_ ''�� Water Supply: Public System and name---------------- -------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silf❑ Clay ❑ Peau' Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe E4 Fill Material_---------If yes, type________-_---_--__--___-_- (Plot plan, showing sizetof 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 Size_t�//- ' '-} _ ------------------------Liquid Depth __ f _-_ __-_____ Capacity_!__.�)Z_ �------Type , f z ---Material 1 `6?'j ----------No. Compartments --------- "'------- ---------- Distance to nearest: WeIL- � __ '------------------Foundatipr�y ._. Prop. Line- `:< LEACHING LINE ] No. of Lines{� '_E_'_C Length of each line.-/6-_- �_�*__-Total Length_____ ___ D' Box_-----------Type Filter Material-__ __ ___Depth Filter Material--------__ _,�-------------------------------------- Distance to nearest: Well__f `4 Y____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___________________._---__--__________--.-) SepticTank (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 becomeqsgb1ect to Wgrkmaq's Compensation laws of California." ! .a --- -------Owner Signed ---'1 -- -- /- BY1. ' j / . --• lS ---- -------Title_ -------- -------- -------------- u.. (If other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______ _ ^� - - - - ---------------- - ----- -----------------------------------DATE --- - - -------- ----- DIVISIONOF LAND NUMBER------------------------------------------------------------------------------------- --------------------DATE---------------------------------------------- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------ -------------------- ----------------------- Final Inspection bY:---------------- �_ O/ - - Date " EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M