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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No---- --------------------------------------------------------- Date Issued.... 7 .................................................. ..... 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: I. JOB ADI]KESS/LOCATION...---��.`��_ --- __-.__-__.CENSUS TRACT Owner's Name---- --- �---- -- --- ------- ---- ---------- -- --- -- ------------------------ ---- --- ------ ------------Phone---------------------------- --- 1.0 Owner's ------�- ------- ---- - ------- �-7� /f City Zip Contractor's Name-------- --- ----- �-" 1�----� . _License #_3'-gz�"6----Phone_ Installation will serve: Residence [7� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------- - --------- Number„of living units:------- -------Number of bedrooms"."... Garbage Grinder............Lot Size---------..._--..""......... ... ----_________________ Water Supply: Public System and name-------------------------------------------------------------- ---------------------------------------- ---------Private 1. Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0� Hardpan ❑ Adobe❑ Fill Material------------If yes, type_________________________.._._. 11 _- (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 GE TREATMENT ( ] SEPTIC TANK [i] 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-----------------------------------------------------------.-. 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 .) bnk (Specify Requirements)"-".-...---."---------------------------- ,I Feld (Specify Requirements)_-> e a-4.,._ f_ Dis osq �` � �--------!` k------- brave existing and required fd4�tiorn on reverse side] I hereby certify that 1 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 signatu�e 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 ,... ---�---,-,l- BY---------------------------------- ---------- inti _Title---f14.0-s, (If other than owner) ii FOR DEPARTMENT USE ONLY 're APPLICATION ACCEPTED BY---- ---C - ---- --------- ---------- ---- ------------------------------------DATE._-f 1--7;,-g-1 7-------------------- DIVISION _- z,-$-17-------------------- DIVISION OF LAND NUMBER--------------- -------------- --DATE--------------- -------------------- ADDITIONALCOMMENTS------------------- ------------------------------------------------------------------------------------ ------------------------------ ------------i--- --------------- ---------- -------------------------- ----- ----- --------------------------------------------------------------------------- -- ------------------------ ----- ----- ----- Fina{ Inspection by:-----ice----------- - ------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M