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FOR OFFICE USE: + '' AP1.PLICATION FOR SANITATION PERMIT FOR OFFICE USE: 4 (Complete in Triplicate) �, Permit No,.-. ._ � ' • --- - " This Permit Expires I Year From Date Issued ' Date Issued--- Application ssued_-Application is hereby made to:the Sari Joaqui6 Local Health District for a permit to construct and install the work herein described. This application is made in complionce with C my Ordinance No, 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO ......_ ........------------------------- -.CENSUS TRACT------ Owner's Name.. - ---------Ph Address l `. ane.._.- t 7 is f.�1-W._..-- City •.�_ . . 'Zip. Contractor's Name.... ......... ----- - License.#-- � 0-�� ..Phone. lnstallation will serve: Residence [�-`"Apartment House 0 Commercial [� Trailer Court ❑ 4 Number of living units:._.: / ---Number of bedrooms.-_ .Garbage Grinder..---- ---- L t Size.....�� - .�a Water Supply: Public System'and name)-_._ ----------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ Hardpan ❑ AdobeAr Fill Material - ... If yes, t )Plot plan, showing size of lot, locationlof 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 avai{able within 200 feet,), n PACKAGE TREATMENT ( ] SEPTIC TANK [ ] f Size ...--. ......... ----------- --------------Liquid Depth.---- ...... Capacity.. Type---- ¢= " Material------------------- -----No. Compartments----------• ----- Distance to nearest: Well------ --------- , -.--_- .Foundation....... - Prop. Line..----...... -,--------_CA LEACHING LINE [ ] No. of Lines ----------...._.----..._..Length of a h,line-----------------------------Total Length ,. .............. ..A 'D' Box---:........Type Filter Material___- Depth Filter Material...".._..._.... r --------------- ------ Distance --- -- -Distance to nearest: Well------------------ Foundation------------------ Property Line..... ........... SEEPAGE PIT [ ] Depth.......... .....Diameter---------------- - • R Rock Filled Yes ❑ No ❑ Water Table Depth--------------------------- -------Rock Size--.-----.... " Distance to nearest: Weil------------------ ----------.Foundation Pr REPAIR/ADDITION (Prev. Sanitation Perop. Line----- .---.._..._. - ...... mit#-- ------------"-_----_"._-- -- ._. ..---.._.Date----- -•=--------- .) _ - ...... . ........... z Septic Tank (Specify Requirements)------ -- -------- ---- 1 Z� aq Disposal Field )Specify Requirements) - -- lie ----- •---- ------------ ----- --_ # ----- --------------------------- -- ----- (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 the following: 3 Laws, and Rules and signature certifies Regulations of the San Joaquin Local Health District. Home owner or licensed agents "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 r to become su ec o orkm s Co ensatioa laws of California." J 3 Signed._.._ --.---- - -- +� Owner By....................----- ---- ------------- - - ... _.. Tit ...................... (If oth than owner) 1 FOR DEPARTMENT USE ONLY � ------- APPLICATION ACCEPTED BY E---_...._.-- -------- DATE ------ (VISION OF LAND NUMBER.----- - DATE ADDITIONAL COMMENTS... .: . .- �� ..-. .( .----- ------- ...-- -------•---- ...... ............"-------------------- -----...._ -------- ------------------------------.---..:........ -----------.------------- e Final-lnspecilon by:.... . --" --- r'- ----- ---- Date.----.tib --��-- ... .... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M