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FOR OFFICE:USE_ ✓ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............... ............ (Complete in Triplicate) Permit No... __"........... ---------------------------..-..... ------------- k ' Date issued".. ..........".""-."..................__..........._...... This Permit Expires 1.Year From Date Issued Application is hereby made to.the San Joaquin Local Health'Dist ct for\.a°permitRto.construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: U -- ------.CENSUS TRACT ----------------- -- JOB ADDRESS/LOCATION......�. ...... .. .LN._. .-.-.. .. .l4 ..._.. Owner's Name.... . ..: - --------- . .....:...:........ . ........ .............. ............ ........Phone....... ----•-•------- ........ .-... Address------- - Cit Zip = ... Contractor's,Name_........��°_ J License #- �'f-7/- -Phone. _ /..�1 ��- o- f ►l t Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other...... ---------------------- p Number of living units:....... ._....Number of bedrooms_. .- _. Garbage Grinde-r..:.........Lot Size.......-. Water Supply: Public System and name------:------------------------------ -------------------._._...........---_---------..........Private Character of soil to a depth of 3 feet: Sand ❑ Silt.❑ Clay ❑ Peat ❑ 'Sandy Loam ❑ Clay Loam r Hardpan ❑ Adobe ❑ 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--.__ .._ I D ...............Liquid Depth____-_-.-----..."-. f� -yy �( i /� ...... Material_ _ .......No. Compartments.._.- - Capacity �-V-� ------.1Ype.�..---- - --- , Distance to nearest: Well-'.....- - ..................... .........`Foun-d`ation-.----... . ...... ..... Prop. Line-.-.......... LEACHING LINE ( ] Na. of Lines _.--------------------Length of each line...._ L t :_--- Total-Length .---..-- -- .."---------'� • rl 'D' Box..J.......Type Filter Material.:... Depth`Filtec..Material-�-�%iJ.f .----------. "" ------ i Distance.to nearest: Well_-_ �-"-____. Eoundation---------- ---------------Property Line........... .. .......... SEEPAGE PIT ( ] Depth._ . __ _Diameter_-_va.P...........Number_.__.._..__"".."""._.` I Rock Filled Yes No C - Water Table Depth--------------- -------------------------Rock Size-- .--- - t ... Foundation........... .......... ...Prop. Line--- .._Distance to nearest: Well.----- --------- REPAIR/ADDITION (Prev. Sanitation Permit#------------- ------ ---------------Dote_-._..-_---- ----------] f Septic Tank (Specify Requirements)................ .... • ----------------- ....... -- -- --........ - ------- --- Disposal Field (Specify Requirements)--------- -----------_ ................. ....... 1 ---------- ---- -------- ------- .....................................................------------------------------- ..-----------•-- -------------- -- - --- ................................................... -- . (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: l "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." Signed_. ; .. .. .................. . . ....... Owner t By.. Title. ( otDher than owner) OR DE RTMENT USE PNLY APPLICATION ACCEPTED BY _O.LA .--- DATE .. jg 75..... i DIVISION OF LAND NUMBER ... ------- -------------DATE.... ------ ------- --------- -------- ADDITIONAL COMMENTS................ ----------- -------------- ------------------------------ --------------------------------- _..---------- ------•-"--------------- ---- ----- - ------------------- ------.......................................... — f ....---.------- y -' .. - R �a f - - Final Inspection by... - ------- -Date... . -- --r. ... ... ... ..... ..... .... EH 13 24 ZqN JOAQUIN LOCAL HEALTH DISTRICT fas 21677 REV. Ana 3M { f � 1