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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---'--- --------------' : ----•-- - Permit No.-2�'✓...... - f (Complete in Triplicate) (� ------------ ..fes... ....._._ l Date Issued.. ....'": ...S`� ................................. .. °._ This Permit Expires 1 Year From Date issued Application is hereby made to the�San Joaquin Local Health District foif'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 -. - :_.__ -. __._ . ------ _ Phone Owner's Name---- Address ame.- Address----------Se a - - - -- -.City----- --._...-------:-- -- ._zip---:. .....------ Phone... . Contractor's Name.._------ - License # o ff . - -0/ 7..... Installation will serve: Residence 0 Apartment .ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------- Number of bedroo :-J�. --G rbage.Grinder_...:.......Lot Size--- 1.0-. -- # Number of living units:.__. -- ��- . Water Supply: Public System and name----_...._._.. .....------ ---.--Private El Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material.- ..-. --_.If yes, type................. -. _. I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) S i 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. Compartments------ '- .. ..... Distance to nearest: Well-:.-�-- .___ Foundation------- .. _____..Prop. Line..... .---------- LEACHING LINE [ ] No. of Lines ..._.._____._.__._.._....Length of eac line _..._.. --------- Total Li npth _._............................__.----^ J 'D' Box.............Type Filter Material.__ ._ Depth Filter Material._. ----------------------- ----------- Distance to nearest: Well-- .Foundation.......... ...............Property Line. Filled SEEPAGE PIT ( ] Depth._ _!.__....Diameter..... _...Number - _ _--__ . Rock 1 Yes E] No E]R ed Water Table Depth .............. - --- Rock Size._ .. ... Distance to nearest: Well.--.--:-- -----------------------Foundation.....-----------------....Prop. Line..-- ----- t.... REPAIR/ADDITION (Prev. Sanitation Permit#. ...----.--- -" ":_:Date.....------------------------...-----------] Septic Tank (Specify Requirements)._._ .. ... .. --- "--� �� i n f t Disposal Field (Specify Requirements)_-. ... t --------- -------- '-----.. (Draw existing and required addition on reverse side) 1 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 Workm Compensation laws of California." Signed.... ----- --- ---- ----- ---------- ------------- ----------- ---Owner BY - - - --- Title------ ---- ---------- --------- (If other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ---- ------ - - -- DATE - - ------- DIVISION OF LAND NUMBE ----------.DATE_-------------_..--- ----- ----------- -- - ADDITIONAL COMMENTS............. ------------- --._ ---- _.__„.............._. ----- ---- - . 5 -- . � ,. --------------- - -- - -. Date.--- `a ..�..-- I Final Inspec>lon by:_ --- - -"'”" -- ---- -------------------`------------------- ---- -------...--------- - ------ --- - EH 13 24 SAN JOAC2UIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M