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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------- --- ------ --- [Complete in Triplicate] Permit - ,'-Date Issued-®®/_-7.V _____________-------------------------------------------- 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__4_7f __._- _ -----------------------------------------..--.CENSUS TRACT---------------------- Owner's Name-------------IQ- ----- - -- ----- -- ---- ----Phone---- ------------------- Address---------------- -- - � --- - --- -- --- _-City--- �' -----------•Zip--9 ^ _I_.`-------- ---------- Contractor's Name -- .�r�<E --��- -�--- --- ( kieense #---------------- r.�Phone Installation will serve: Residence ❑ Apartment House Comm rcial❑ ,Trailer Court E]Motel ❑ Other____ -Si. Number of living units:--- "-----__=Number.of_beslrooms----r__Garbatge 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 ❑� 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 INSTALLA71ON: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT C ] 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-------------------- ------------------7k 'D' Box------------Type Filter Material--------------------Depth Filter Material--------------------------------------------------------------- Distance to nearest: Well----------------------------Foundation----------------------------Property Line---------------------------------_ SEEPAGE PIT [ ] Depth----------_-----Diameter.-------------------Number-------------------------------- Rock Filled Yes ❑ No❑ Water Table Depth-------------------------------- -Rock Size------------------------ Distance to nearest: Well___________________________________________Foundation--------------------------Prop. Line-----.______ _,.._. REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date_..._.----------.----------.-----------------_] Septic Tank (Specify Requirements) ---- ------------------------------- --------------------------------------- DisposalField (Specify Requirements)---------------------- -------------------------_------- --- -- -------------------------------------------------------------------------------------- -------------------- ----- - (Draw existing and required addition on re se se) 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 "1 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." Signe Owner B -------------------------------------- ��1�-�-- --- - -- _ -- -- =-�-jam'------- Title._�_�_�-t-Z Z 4Ca1-,,"'------------------------------------ (I f ------------------------------- -(If other than owner) + FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 'BY------C..-- ----------DATE ..J!.r___�j. .'---- ---------------------- DIVISION OF LAND NUMBER. - - _-- - - ---�--------=--.DATE---------` ------------��. 4 ADDITIONAL COMMENTS--------------__.2------------------------ ----------------------------------------- ----------------- ------------•------------------------------------•------ y _ --------------------------------------------------------------- .--. _ - _._ =----------------------------------- ----- -------------------------- -- --------'---- ------------------------------- ----------------------------------- ----------------------------------------------- �^ - -- ------------------- FinalInspection by:.--- -- - - --------------- ------------------------- ---------------------------------Date EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M