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r FOR OFFICE USE: FOR OFFICE USE: S --------------- ---- APPLICATION FOR SANITATION PERMIT Permit No.-- 7 a Yvz� Z ----------- (Complete in Triplicate) `" ....... _ Date issued_.__ -------------------- ----------- 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: I JOS ADDRESS/LOC l N.._ ®._ , __ CENSUS TRACT.".___._____-"_____________'_ -- ------- - f Owner's Name.- - --' -- -- --- --- --- ---------------------------------------------�---------- --- --- ----- - — ... Phone_��=.✓�r7- -.�� -- ------------------------------ Address ----- -----------=City..-- --------------------Zip a ----- - Contractor's Name"_. r ------- -- --------------------------- License # Phone ---------------------------------------4 Installation will. serve: Residence W-� Apartment,House.❑ Commercial ❑ Trailer Court ❑ ' *'Motel'❑' -,Other___'____.___ Number.of.living urirts: ____.Number of bedrooms-2 -Garbage 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�Elay Loam ❑ Hardpan❑ Adobe ` Fill Material__.__'.__.__If yes, type___________________ (Plot plan, showing size of lot, locat.ionof system"''.'.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,] a PACKAGE TREATMENT [ ] SEPTIC TANK [ Size___ ____________________..____________._.___________Liquid Depth._______;__.____ CapacitY � ype -- ---Material--------------------------No. Compartments------`��--------------_-- .' ! e AT. Distance,.to nearest: Well.---/," Foundation--� --------------------Prop. Line-------------------- -!-- LEACHING LINE . . NDo':'of "in_.e'"s----s #,._ .-----�' Length of each line --- ---- - - ---�"-"__.Total Length."-."_".."__-.""------------- ---- R Box'4TYPe Filter MateriaL___________________Depth Filter -------- __r ; Distance=to nearest: Well___._7-______-_____"__.Foundation___:_____-.________.___.Property Line___._____________________________ SEEPAGE PITS[ ] ! Depth---------------_Diameterle"` _-------------Numberti_"""""_"_".. ff"__r----__.____ Rock Filled Yes ❑ No Water Table.Depth---------- --- --- ''" f ! Distance to nearest: Well----------- -----------------------------------Foundation---------------- -------Prop, Line--------------------------- REPAIR/ADDITION --------------------- -REPAIR/ADDITION (Prey. Sanitation Permit#-------------=--------------------"-"_-- —Date - ---------.----------------------------_] Septic Tank (Specify Requirements) . cl � ------------ Disposal Field (Specify'Requirements)---------------------- ---------- --------------------------------------€--- € i -------------------------------_------ --------- --- -------------------- ----------------- -------------------- ------------------ -- -------------- ----------- ------------ --- -- - --- - -------------------- -- { (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: r "1 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/s1ubject to Workman s. Compensation laws of California." Signed- ------------- ' -----i----- --- :-- : -------_Owner BY — =------------=------= ---'-------------------------------------- Title-.-------- (If other-than owner) 4. t FO DEPAR ENT USE ONLY ` APPLICATION•ACCEPTED BY -- --_-- -_ _ - _ ___Q �`/ ---------------------------------DATE --- DIVISION OF LAND NUMBER.--- ----- -�_ 111111 ----------- - ------- -- DATE.------ -------------- ---------- ----------------- - -------------- ADDITIONAL COMMENTS ----- ------------------------- ----- -----1---------------------------------------------------------- i --------------------------------------------------------------------- ------- ------------------------------------------------- f. ----------------------------------- Final Inspection by Date. i EN 13 24 SAN JOA N LOCAL HEALTH DISTRICT F85 2!677 REV. 7/76 3M