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FOR OFFICE USE: FOR OFFICE USE: ------------ APPLICATION FOR SANITATION PERMIT O ,0 (Complete in Triplicate) _ Permit No._7�_"___ -_�_� --------------------------------------------------------- - This Permit Expires t Year From Date Issued 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-.- 0_6 __________________________CENSUS TRACT-_______ Owner's Name------------------------- - --- - -----.Phone /-_/�7 ------- Address -------------------- ---- -- - - -----------------City_ zip------------------------------ fName------------ - -.�-- -- --License #► ,S S Phone- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Q Other--------------------------------------------- s Number of living units:----- --------Number of bedrooms -5-----Garbage Grinder------------Lot Size_. � Water Supply: Public System and name----------------------------------------------------------------------------- -----------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑. Clay ❑ Peat❑ Sandy Loam E] Clay Loam 2r, 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 [ I Size-----------------------------------------------------------Liquid Depth--------------------------- Capacity.-------_ -.___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---------------------------------------------------------------- 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)----- x/S'- 1 __6------------ - -- -------- ' i Disposal Field (Specify Requirements)SCt �D�e/� �P.rv�flygB — /� �' ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 int performance of the work for which this permit is issued, I shall not employ any person in such manner as to becomtubject orkman's Comp sation la s of California." Signed--------------- -12,1 �s 4( --------®h '6w �/`` By----------------------------------------------------------------------- - - �"``""' - - -- -- ---- ----------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ` --------------------------------------DATE ------ �__ _•� DIVISION OF LAND NUMBER-----------------------------------�f------- ------------------------------------------------.DATE_----------------------------- ------ ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------ ----------- -----------•--------------------------------------------- ------ ----------------------------------------------- -------------- - ------------------------ -- ---------- --------- -------------------- - - -- -- -------------------------------------- ----------- Final Inspection - Date_ __ _._' ----------7-7------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M