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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 77`y�3 --------------------- ----------------------------------- 1complete in Triplicate) ---------------------------- Date Issued _ ----- � This Permit Expires I Year From Date issued __ - Application is hereby made to the San Joaquin Local Health District for a permit to consOrdinance No. 549 and existing Rules and Regulations: truct and 'install the work herein described. This application is the S n compliance with County r W ZD- - CENSUS TRACT ( JOB ADDRESS/LOCATI _ -� 1" I"— / ----- - -------- - Phone -.---- 2� v c� 1Q_ � _, -r--------------------------- _ ------------------ Owner's Name / ------------------------------ Address --------- ---- --- - -�,C)" ,/------- - - --------•--� city �, -� - - � "� `�fK --- Phone�.----------�---'-- = - �" ^– t License # : Contractor's Name ----- /'�-�- -----� -� - Installation will serve: Residence F1 Apartment Hou se❑ Commercial:❑Trailer Court Motel ❑ Other --------------------------------------------------------Grinder "----.__" -- Lot Size .__ __ --- Number of living units:__/------- Nu mber of bedrooms -"--"------- -----Private ❑ ------------ ----------------------------------------------------- Water Supply: Public System and name ----------------------------------- Cla Loam:❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat EJ Sandy Loam ❑ Y R , _ . .:. It Hardpan X Adobe'E] 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.) public sewer is available within 2d0 feet,) NEW INSTALLATION: (No septic tank or seepage pit permitted if p (( SEPTIC TANK'[ l Size-- ---------- ---------- --------- - - Liquid Depth -----------------•-------- f p PACKAGE TREATMENT [ ] � - No. Compartments Capacity -------- --------- Type -------------------- Ma rial----------- --- ---- -----------Fou ation ----------------------.Prop. Line .------ Distance �to nearest: Well "--_.------------------LEACHING LINE [ ] No. of L"Ines "------------ ----------- Length of each line-- ----------- ---- ------ Total Length ----------------------------- LEACHING --------------•------------ --- a th Filter Material -------------------------------------------- 'D' ------- ------- ---•----------•--•--••---•-D' Box ]----- - - Type Filter Material -__-"------" -- P Property Line --------------------- Rock ---------------- -- k Distance to nearest: Well ------------ ----------- Foun ation --------------- p SEEPAGE PIT L 1 Depth ------------ Diameter ---------------- N mber -------------------- e ---- - ----------- Rock Filled Yes ❑ No ❑ F Rock Size - " Water Table Depth ------------- --------------- Foundation Prop. Line ---------------------- - Distance_ to nearest: Well _ ---_ - tDate ----------------------------------1 REPAIR/ADDITION(Prev. Sanitation Permit ------------------ ---- ------ - f Septic Tank (Specify Requirements) ------------------------------------- ----------------------- ---------------------------------------------..- ------------------------ f Disposal Field S ecify Requirement ----------- --------------•--- ------------------ --- ---- : ------- �-� � c�--- ----------- � ----------------------------------------- -------- _ � �1---" -------------------------- ------------------ --------- (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 of the San Joaquin Local Health District. Home owner at licen- County Ordinances, State Laws,sed agents signature certifies the{and Rules and Regulations following: f "I certify that in the performance of the work for which this per is issued, ! shall not employ any person in such manner as to become subject to Workm ,s Compensation laws of California." Owner Signed ------------------------ rte' Title ---- ------------- ------- ------------------------------------------- Y ------------- .(If other t an owned FOR DEPARTMENT USE ONLY DATE --,�`��-.7�-=-------• APPLICATION ACCEPTED BY '-y--� �r� ------------------------------------- --------------------- ---- DATE ------------- -------------------------- ---------------------------------------- BUILDING PERMIT ISSUED ---------------------------------------------------- -------- ------ - ----------------- ADDITIONAL "" ----' ADDITIONAL COMMENTS ------ " ------------------------------------------------------------------------------------------- _--_- ------------ --------------- --------------------------------------- - -------------- --------------------------- - ---------------------- ------------ --------------- ------ ------------------------ - --------------------------------------- "r r77 ------- -- _ __-"__ - ate Final Inspec ' SAN JOAQUIN LOCAL HEALTH DISTRICT F H 9 1-'6B Rev. 5M