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'FOR OFFICE USE: FOR OFFICE USE: ~ APPLICATION FOR SANITATION PERMIT ---------------------------------- CC (Complete in Triplicate) Permit Na _�-=Q._a -- --------------------------------------------------------- __ __ This Permit Expires 1 Year From Date Issued Date Issued_ f1'_.d_` -77 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�549and existing Rules and Regulations: 5 % . JOB ADDRESS/LOCATI � ---__ _ .Q-- -- MS'L°I5'YRACT.------------------------------- r / - t Owner's Name.._' - ` - ti' = -- -- ---------------------- - -------------------- Phone, t` 7 �f�� _.f - f --- -- - --- ---- ------- Address-2-4 ------------------ aCit; ---------------- ---------- Zi �, � 's Name - ---- ---- ----License # - Phone- Contractor � r3l.� Installation will serve: eside ce; art�`H' Commercial Trailer.-,Court , } p 6, ❑ ❑ Number of living units_________________Num er of bedrooms_�-----Garbage Grinder_.._. __CLot Size_.,..-�--.-------------- ------------------------------------ I _._____._.___._._._______...__. Water Supply: Public System and name-------------- --- --------- -- -----I-------------------..- ---- ------ -= Private t Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loa Hardpan ❑ Adobe ❑ Fill Material_----------If yes, type------------------------------- (Plot __.________________________(Plot plan, showing size of lot, location of system in relation to y el-l5, uiLbings, etc, must be placed on reverse side.) NEW INSTALLATION: - (No septic tank or seepage pit permitted if puBlic sewer is available within 200 feet,) i I r, PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ,Q0 �Siize��_ --- -------------Liquid Pepth Jr ' Ca acit � " C1��d_Material_ No. Compartments}P Y �pe partments ------- - - - - - - - ----- Distance to nearest: Well____ �____________________-------__Foundation--le_--------------Prop: Line._�Q__ - � LEACHING LINE f� ] No. of Lines__ ______________ Length of each line____________-____-___-.-._.Total Length __. ----_ t 4 D''Box--- ------Type Filter Material_ ____Depfh_Filter Material---.GfJ---------____________________________ r Distance to nearest: Wel l--------_-------------------Foundatio W_.-___._--_______________--Property Line---------.--------_____ SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-- ------- --------------- Rock Filled Yes E] No ❑ WaterTable Depth--------------------------------------------------- -.Rock Size----------------------- ----------------------- Distance to nearest: Well-- Roundation--------------------------Prop. Line--------------------------- C a REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------ate--..---.---------------.----------------------) �b Septic Tank (Specify Requirements)____________________ ti Dispose! Field (Specify Requirements) J4_-_- �74i -------- -- ----- ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ----------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------------------- (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 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." --- ----Owner -- Signed-- [ - -- - ------------------------------- - BY------------------------- ------------------------ --- - - -------------- ------------Title---------------------------------- --------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___ - -- -----------------------DATE.- _ Y�j�'-'7�------------- DIVISION OF LAND NUMBER.------------------ ----------------------- -------------------------------- ----------.DATE------------------------------------------ ---- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - ------- - - ------- _ !g-- -----? Final Inspection b _rx ! `I - ---------------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M