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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) � ----- ------ ------------------------ --------------------- Date ------------- _________________________________ 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 comI!fe w•thh County Ordina r No. 549 and exi�S Rules and Regulations: JOB ADDRESS/LOCATION--- - --- --- --- ------ ENSUS TRAM Owner's Name. - J�'-- y � � Phone_v. �Q_� Address. A � �- _ ---Cit Contractor's Nam -- --C-----------------C _ -.-- --- ------License #_��-F��L�-�------Phone��f.'_��1.----�------ Installation will serve: ResidenceApartment House.❑ Commercial E] Trailer Court EJ ❑ Other--- - ---=--------------------- - -- - Number of living units:__..__/------Number of bedroom s___�.�-Go rbage 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 ❑ AdobeFill 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 INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] Size ------Liquid Depth.------- ---- ------ -----�1 PACKAGE TREATMENT [ '] 'SEPTIC TANK [ j Siz .------------- Capacity-------------==-----'Type----=------- ----------Material- --------------=- =--No. Compartments-- ------ -------------------------0► Distance to nearest: Well..._.......-................................ Foundation--------------------------Prop. Line--------------------------- LEACHING LINE [J No. of Lines----------------------- - -=Length of each line-------.:---------------------Total Length.---------------.-----------:-,_-_---_-'-- s 'D' Box...s_�_�_Type Filter Material.--- --------------Depth Filter Material----------------___.__._____._.__.________________.__.___._._ R Distance to nearest: Well- --------------------------Foundation---!------------------------Property Line---------------------------------- _ - I�¢,� !- _ .. _ � - SEEPAGE PET [ ] ) Depth-----------------Diameter---------------------Number___.______r.�---------------- Rock Filled Yes ❑ No❑ Water Table Depth--- ----------------------- ---------------------- Rock Size i I [ Distance-to nearest: Well-------- ----------------------------------Foundation------------------------- Prop. Line---------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------------------------------Date-�-.^----------.-------------------- `--------j Septic Tank (Specify Requirements - -- =-�_ ---------------------- `-- . - ---- - ----------- ---------- I t Disposarecify Pquir'me ) - '�-- ----- ----------------------------------------------- ----------------------------------------------- --------- (�---------- --------------- -----•----- ` ----- ---------------------------------------- ----- --- i -------- -------- ------. t (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." t t s ° Signed ------ --•---- ------------------- -----------------------------------------------------------Owner - F (If'other than -ow ner)� -- --- Title ---------------------------- By ' -`- ----- - FOR 1. DEPART NT USE ONLY APPLICATION ACCEPTED BY ~.--- -----------------DATE f -- i DIVISION OF LAND NUMBER --------.:'_----_. _ == DATE = - ADDITIONAL COMMENTS----------------- --------------------------- -------------- - -------------- �. ------------------ ------------------------- _ --- - -- - - _ ------- ---------------------------- ------ - --- ----- oection Date c-. -7 �------------- b - Y---- SAN JOAQUIN LOCAL HEALTH DISTRICT Fns 21677 REV, 7/76 See