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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOIrSANITATION PERMIT j ------------- - ,f ----.... (Complete in Triplicate) Permit No.. ---------------------------- ....--------.. f/—// 7� Date Issued--7--....-~----- ......•------•••-- ----------... This Permit Expires 1 Year From Date Issued I Application is hereby made to.the Sant Joaquin Local Hea'Ith 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: r � - • - JOB ADDRESS/LOCATION.,,/--i. _-_-..CENSUS TRACT..---- --------------_--- Owner's Name _.. . Phone . . ................... . ••---•- - ---- Address..... ..... _... City ------------------------ ----- - --ziP------------ .......--------- Contractor's Name........... ...License #-. - .. ..Phone_.. _. �_... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ j Motel ❑ Other Number of living units:-------1-------Number of bedrooms- ...Garbage Grinder............Lot Size._--O.W. .�.� -- ----------------. - .- r I Water Supply. Public System and name................./.... j... ............ --•------------- ...... .......... -----------------Private ❑ Character of soil.to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loa rry i 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,) F PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size --- ------------ Liquid Depth ....-------------- A - Capacity../_9.P_V_._Type_--_4 Material.-. . ..........No, Compartments..-_ , Distance to nearest: Well- _ . _----.._Foundation..-__ ..�.....- .. - Prop. Line------`�................ LEACHING LINE [ ) No, of Lines . ... ..... ............Length of each line.:../_G4-._.._--.--_-:__Total Length ................. 'D' Box...........[.Type Filter Material._./K... Depth Filter Material.. DistancDto nearest: Well__1 -....Foundation-------------------------^'-Property Line...-._.___--.- ..........� i SEEPAGE PIT [ j` Depth.... g`...Diameter_.��..------ Number_....j_...._................. / Rock Filled Yes �" No i .. t Water Table Depth------------------------ ---- - - --- ------------------Rock Size.- ./.... Distance to neI arest: Well--............. .....Foundation....... . ..._.Prop• Line...._...._.._-.-_ REPAIR/ADDITION (Prev. Sanitation Permit#........................... ........Date.-----.._.-----------_------- -----_..--._._) Septic Tank (Specify Requirements)- --A. --- ---------------•-----•-- ---..----- - -----------.............................. -- --- -----------••-•--- . .... Disposal Field (Specify Requirements) -= ------------ ................ ---•----------------------- .... -------- J[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 i 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 mariner as to become subject to Workman's Compensation laws of California." Signed._ .. .. ----------------- --------------------------Owner I By-------- - ....... Title.------ ....... (If other than owner) " OR EPARTMENT USE ONLY APPLICATION ACCEPTED BY........... --. ...... ..... - - ! DIVISION OF LAND NUMBER. ,p DATE ..----- -- ------ .. ADDITIONAL COMMENTS_.. -- -- _... -------�. D.l- ...... -. ----------- - -----._....--. -- ------------------------ ---------------------------------------------- ------------------------------- r -. ----•------ ------- ............... ................... .. ... .• --••--------------- ------_--_--------•--•-----. --------------..... .---.-- -----------•---------- ------- a Final Inspection by:....------- l°'�------------ ---------------------------------------- ----------Date...__��../_2 ._.. -- . EH 13 24 S JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M i