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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No________________ Date Issued.�7-,;�?_7e ------------_---__-------____---------------------_------ 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: �' !/' ?' ---------------CENSUS TRACT__JOB ADDRESS/LOCATION � ._ -- � ---- --- �-------- , Owner's Nam.e_----�-- '" - Phone. Address-------------- --049P40o � _ _. Ci --------------------------Zi Contractors Name- �^ License #__, a8 Phone Installation will.serve: Residence ❑ Apartment House.❑ Commercial eTrailer Court ❑ Motel ❑ Other------ ------------- - Number of,living units:._,.;. ''_.___Number of bedrooms_.-�:.-__Garbage Grinder_.__^.___Lot Size________-d Jam" `_ ------ --------- ---------------- Water Supply: Public System and name = ---.-------------------------------------------- -----------------------------------Private ❑ Character of soil,to a depth of 3 feet: Sand ❑ Silt❑ ,Clay ❑ ` Peat ❑ Sandy Loam IM/ Clay Loam ❑ ,Hardpan ❑ Adobe ❑ Fill Material-------------!f yes, type-------------------------- ----- {Plot plan, showing size of lot, location of system in relation to wells,"buildi6gs;-etc. must be placed on reverse side.) NEW INSTALLATION: .(No:septic tank or seepage ,pit permitted if public sewer is available within 200 feet,) .ul PACKAGE TREATMENT [ ] SEPTIC TANK I l €Size-------- -----------------------------------------Liquid Depth_--------__----_-----__ ___„J A Capacity-----------------------Type-------=---- #---------Material-------------;------- ----No. Compartments----------- ----- + Distance to nearest: Well________________i.--------------' C ----------:Foundation- - .-..-.._ - = Prop. Line - ----. LEACHING LINE. - [- ] Na. of Lines._---=___---<-------------Length of.each_line ,----------; ---------------Total Length ------ ------------------------- t 'D' Box------------Type Filter Material-_..--------------Depth Filter Material--------------------------------------------------------------- I Distance to nearest: Well----------------------------Foundation------------------------------Property Line____________________________________ SEEPAGE PIT [ ] Depth-----------------Diameter--------------------Number__------------------------------- Rock Filled .Yes ❑ . No ❑ WaterTable-Depth--- ------------------------------------------------ ----Rock Size------------------------------------------------ o i Distance to nearest: Well----- ------ --------------- -- ------ ---- Foundation--------------------------.Prop. Line----- ---------------------- REPAIR/ADDITION - -------------- --REPAIR/ADDITION (Prev. Sanitation Permit#------------- :------ ------.Date-------------------------- --------------- --- Septic Tank {Specify Requirements] ------------- ----- ----- ----- == = ----------- -------------------- Dispo I Fiel (Specify Requirements)_.___ sr�r6 _- t� -------- ------------------------------- "�___ - ------------------ --------------- ------------ Q--p-d- •------ ------ --- ----- - ---------------------------------------------------- ----- ` „ Y ;, .., a- ` ---- -------------- (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 perforinance'of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed------- ----------------------------------- ------- -----------------Owner BY------- ------------------------ -------------- . ---------- -- Title ----- (If other than owner) FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY -- -----------------DATE. DIVISION OF LAND NUMBER._ -..----- --'------------- -- ---- DATE-----------------.___-- ADDITIONALCOMMENTS----------------------------'-------------------------------------------------------=------------------------------------------ ------ - ------------------------------------- ------------------ ------------ ---------------------- ------------------ ---------------- ------ ---I---- ------ -----------_----- ------- -------- ---- ------------- -- -------- ------------------------------- - ------- - -- -- - ----- - -------- - �=-- -- ------ ------------------------------ ------- ---- Final Inspection by - /- - - --= ,- - - - Date d - -- EH 13 24 / SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M