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--- .FOR-OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No----_._---------------- -- p p --------------------------------------------------------- Date -•------------ -------------- ---------- -- This Permit Expires 1 Year From Date Issued Application is hereby made to the Son 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: JOB ADDRESS/1_0TION_ 1 G -, -------.CENSUS TRACT Owner's Name_-- -- -- - Address _ - �-. f` = ::�%. �� one ----------------------- t =City ---------Zip--�`�� ---------- ---- Contractor's Name-_ �� p License❑#- _ _ ---Phone-- `�'� � �� ---------- Installation will serve: sidence Apartment House Commercial -Trailer Court ❑ MotelOther . ❑ = -------------------- ----------- - Number of living units---------- ------Number of bedroom s__1-_-__Garbage Grinder---___-- -Lot Size=_----___---,_----------- ---------........... - ---'- -- Water Supply. Public System and name------------- vats ---------------- Character of soiLto d de th-of 3-feet: -Sand.❑__ Silt[]� C_l.ay,l❑ .-Pe_tf ❑' ` Sandy•Loam E3._ Clay Loami Hardpan ❑ Adobe E] . Fill Mater ia __._ -- es, type-- ----- ----------------------- Pot a o 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:pii permitted if public sewer is available within 200 feet,J PACKAGETREATMENT.,•�[ ] SEPTIC TANK [ ;r t Siie - _- \� -----------Liquid Depth -------------------- E # Material -No.`Compartments--- ---:97------ ------- ------- Founclation../,:�/ Distance - Distance to nearest: Well_._ L� _ , _ Foundation.../ ?rop. Line LEACHING L1NEI fi � � �' �� f [F:] No. of Lines-_. ----- --- ----------Length of-ea.ch line,_ ------Total Len th..�.�d_ :� � fig - -------------------- I i D' Boy !.-------Type Filter,Material-_ _ Depth Filter Material---Z__-__ _ Distances to nearest: Well --------v ._- Foundation----------a-----------------Property Line-------------- -------------------_� SEEPAGE PIT [ ]� DepthS�.w'--;`'�---=Diameter- -=--------a- -Number------ ------------------------ Rock Filled Yes'❑ No ❑ Water Table.Depth yy .. --------------- Rock Size---------- - _ Distance tonearest: Well_- * = -----Foundation_--- ---------- Prop. Line-------------- -------------- ---------------- --------- --__.____-_- -fREPAIR/ADDITION.(Prev, Sanitation Permit -----------------------------Date 1 Septic Tank (Specify Requirements)--------------------------------- Disposal Field (Sipecify RequriementsJ----------------------- ---------- ---`-- --T—� --------------- ------------------------------- ' ----------'" ------------- ----- ------ ... ------------------------ d - ' [Draw existing and required addition on reverse side) ,. I hereby certify that 1 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 ther 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." Sagned._ f �--------------------------------- -- / - +_ caner By-:- - ------------------------- - ��,, tl_e -- --- -- Ti: r ------- ---------� - -- [If;other-than-owner) �""� �. t �DEPAR�TME �USONLY APPLICATION ACCEPTED-B��,�FOR -- DATIVISION OF LAND NUMBR.--- ------- -- - - ------------ -------------- ----DATE.----- ------=----- - ------------------- ---------- . ADDITIONAL COMMENTS___.--- : -------- ----------- ----------------- FinalInspection by-------- --- -- 'Date__---- - - - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677 Rev. 7176 3M