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FOR OFFICE USE. FOR OEFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------- 7 _ a s (Complete in Triplicate) Permit o.... ....�...... ------------------ ----------------------------------- - Date issued.7:jpl.:'? ......... ............... .-_...-......... 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/LOCATION.... ., ..__... Q-----Oj. 0-----------------------------------------------CENSUS TRACT....................... Owner's Name.... .... /g�L , 7�........... ............ ...........:. ........................... -------------Phone. ------ Address------- ----Address-------�-�� .... - � � ../... ��s' .. ---- - --- - -------city-S.M. r .................Zip /K..��-�*yy Pr� -..6� Phone-Contractor's Name_ L - 77 . Installation will serve: Residence Apartment House ❑' Commercial ❑ Trailer Court ❑ Motel ❑ Other-- - ----------------------------------------- Number of living units:..... .........Number of bedroom s.- 2.{..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 ❑ Clay Loam ❑ Hardpan ❑ AdobeZ Fill Material.. .... ....If yes, type........................... .... (Plot plan, showing size of lot, location of system in relatiori-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 --------------------------- -----------------Liquid Depth..-.:......__....... 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..----...............---------------------. - -----.-_....--- Distances to nearest: Well----------------------------Foundation -------------------- Property Line.-------------.---- , SEEPAGE PIT [ ] Depth__.... Diameter--------------------Number._---- ----- ------------ Rock Filled Yes ❑ No iWater Table Depth---------- ------------------ ............................Rock Size----- -- ----------------------------------- Distance to nearest: Well----------------------------------. ------Foundation--------------._._....-...Prop. Line-._ - ------------- -----.- REPAIR/ADDITION [Prev. Sanitation Permit#..........---------------------------------`.....Date-------•......-----.------.-------------------] Septic Tank {Specify Requirements]--------- -------------------•--------- ........... --------------------------------------------........ ...... ....... Disposal Field (Specify Requirements).-------- /----...-• ••-, � ----- --------------------;.....-- .-..-1 - --------------------------------------------------- -- ----------------------------- -------------- (Draw ---- .-- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that'ihe-'work will be• doine lin axcardance 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-•---..-:. - :. ........ other (lf other than owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------\c CA. --------------- ---------•-•-- --------------•...........DATE ... .. t�... .�.. --- DIVISION OF LAND NUMBER -------------- ---------- --- ----- ..............DATE---............. ...... ADDITIONAL COMMENTS------------------ .............. ------ . . -- ... .......... -----......-•--------------------------------•---...------------------ ---------------- ------ - ---------- -- .-............... .... ......... ---------....�--- - �. Final Inspection b G�-� -ua— a --- v'' Date. c ................ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F65 21677 REV. 7176 3M