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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' (Complete in Triplicate) Permit No----------- ----- -- This Permit Expires 1 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: , y JOB ADDRESS/LOCATI N.f��, ' Y -- ------ ----------- ----------------CENSUS TRACT----- -- --- Ow Name_ E6 .- a --------------------------------------- -------Phone_ G Address_ d a ----- city-_- . ---------------------Zip-_7Kf _ Contractor's Name-_ . _.,_: n Ph dA --------------------- --------------Lice se #-<-- - -�.1 $ on Instailation will serve. ie's�idn,,f .�partment House.❑ Commercial ❑ Trailer Court ❑ y Motel ❑ Other--------------------- ------- Number of living ___ Number of bedrooms ' -- ------Garbage Grinder-.__- ---Lot Size------------------7!,- t ---------------- Water Supply. Public System and'name ---- Private - . ------ --- ---------------------- 9 � Character of soil to a depth of 3 feet: Sand El lt© E] [-] E]Clay Peat Sandy Loam Clay Loam ❑ + Hardpan Ads, iobe . Fill Material__._-:._____If yes, type-.-______-._ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.4must be plpced on reverse side.) NEW INSTALLATION: (No' septic tanktor seepage pita- ermitted if public sewer is available within 200 feet,) S PACKAGE TREATMENT .[ ] SEPTIC TANK Size__----------------------------------------- __.:_:_ ` - p P h ------------------=---------- Liquid e t -- Capacity �J - ---- pe-- ��.x ----Material--------------------------No: Compartments-----21 --- i Distance to nearest: Well_ 03!Q --k_i_ -- ---__---_-Foundation_Je.- ____._-___.Prop. Line:. Q_�__________ _ � . LEACHING LINE [.] No. of Lines.... ___________________Length of each line--- ---.-'-_-.---__'____.Total Length.-�------------------------------- 4-Depth p`_____-- _ _ w ------------------------------------------------- 'D' � -------- D' Box= ._ =Type Filter Material;-AltDepth Filter Material_. _______.____ ____ ,. - --- --- J . Dis#once to nearest: Well---- -------------------------• Foundation______ _ _ ____ ________Property Line----------------- - ...., ..,... ;may. �.v ., � SEEPAGE PIT [ ] Depth-----------------Diameter.-_-----------_. _Number__-- r_s_= Roc F Ye N M k „ 3 s ❑ o , (Nater Table Depth ----'---------- --------------- -----------Rock Size-."'-" Distance to nea're'st. Well--------->--------'-----=---_c_-'--- --- Foundation--------------------------Prop. Line--------------- h REPAIR/ADDITION (Prev. Sanitation Permit#-----------_ ---------------------------_---------Date__ __._..__________ ; -------------------------] Septic Tank (Specify-'Requirements)---- `-__---`__________ -------------------------------- Dis osal Field (Specify Requirements) - - - - - ... -3 3 ---- -------------------=----------- --- (Draw existing and required addition ori reverse side] " I hereby certify that.] have prepared this application and that the workywill�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.". Signed._ . . , t ----.. i G' Owner € BY --------------------------------=------------ -------- -----.Title------------- 0:f other than-.owner). P FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__-__ - ------------------------- -----DATE. J 7 ' DIVISION OF LAND NUMBER. --- -- -------------- ---------- -----------------DATE------ ------------ - -- --------------- ADDITIONAL COMMENTS ------------------------•-----_ ----------=-------- ------------- `-------- ---------------------- -- -------------- -------------- J ---------------------------------- ----------------------------------------------------------------- ---------------- ------------- Final Inspection by:--=�` �� = Date----- �. - -- ------------------------- -- r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 2307 REV. 7176 3M