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FOR OFFICE USE: FOR OFFICE USE: F APPLICATION FOR SANITATION PERMIT -` - ------------- ------`----------------- Permit No..7_,2-J/s 7 (Complete in Triplicate) ------------------------------------------------------- -- Date lssued__6'__z__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 ounty Ordinance No. 549 and existing Rules and Regulations: CENSUS TRACT-------------------------------- JOB ADDRESS/LOC 10 _. -------- �- �/ Owner's Name. 2/..-.------`'"�---------------------------- Phone G-------- F------ ------- CitY Zip, Contractor's Name------------------ - <C` ----------- -----------License #_0?7Phone... 5_� f/� Installation will sesrve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other------------ ---------------- ---------------- t Number of living units:____ - ____Number of bed rooms...//.Garbage Grinder-----------.Lot Size-47.0.. __/0-1(_2---- .-_,__-_ Water Supply: Public System and name- -..........,.-------------------------------------------------------------- -----._-----------------------------------------Privatex Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe,9 Fill 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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth--------------------------t?1 Capacity---------------------TYpe-- ----- -.Material------------- No. Compartments--- ------------------------------ Distance to nearest: Well-------------------------------------------Foundation-------------------------Prop. Line---------------------------- LEACHING ------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 E] No WaterTable Depth---------------------------------------------------------Rock Size------------ ----------------------------------- Distance to nearest: Well-------------------------------------------Foundation-------------------------.Prop. Line--------------------------- (Prev. Sanitation Permit#---. -----------------------------------------Date----------------------------------------------) Septic Tank (Specify Requirements)------------------ -- ------------------------ ------- ----------------------"----,------- ---------- Disposal Field (Spe ify Requirements)_; �,1,.. _ /� r ------------ ----4taef � - - -------.--------------------- ---------------------------------------------------------------------------------------------------------- - ---- {Draw existing and required addition on reverse side) 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. Hoene 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 beco ub' ct t ork an's Compensation laws of California." Signed-- &Cj - ----------------------Owner BY ---------- �� - ---------------------Title.... - ----- ---------------------- (If of er than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY / ---- -------------------------------------- -------------DATE.-G-�-r 77- ----------------------- DIVISIONOF LAND NUMBER--------------------------- ----------/--- - ----------------------------------------------------- -- DATE----------------------------- ------ ADDITIONALCOMMENTS------------------- ----------- ----- -------------------------------------------------------- ---- --------- ---------------------------------- --- ----------------- -------- -------------------------------------------------------------------------------------------------------------------------- ----------------------------------- --- Final Inspection by:-- .- - Date.- -�- 7--------- ---.----- --- -- ----- ---------- ------------------------------------------------------------------------ ---------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. "