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FOR.OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ------------------------------------ -------------- Permit No.- _- ..__ 5 (Complete in Triplicate) ------- --------------------------------------------------------- +-, This Permit Expires 1 Year From Date issued Date Issued__1____ _7 "9 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 Or finance No. 549 and existing Rules and Regulations: JOB ADQRESS/LOCATIO _.. L ------------ --- --CENSUS TRACT.---------- ----- ------ �1.----±-- --------- Owner'shame----- -- Phone Address--- _ _ - City G� -----------Zip----------------------------- -- Contractor's Name- - P r `{ _ -cense # Phone Installation will serve: Residence❑ Apartment House ❑ Commercial Trailer Court EJ .. Motel ❑ Other......;:7 -ei _... Number of living units:.. ______Number of bedrooms_�___Garbage Grinder------------Lot Size-_4: 111 r --- -------- _ _ Water Supply: Public System and name---- ----------- ---------------------------- ------------- ---------------------------------- --------------------Private. . . ., Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 'Clay ❑ . Peat L Sandy Loam ❑ Clay Loam [?}- 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 seep ge pit permitted if ublic sewer is available within 200 feet,) PACKAGE TREATMENT [ j SEPTIC TANK [� Size_��_____ _��_rr _r �_---------------Liquid Depth----- _____/_ ! r Ca acit oz�._-_._T � _Material ___ - p Y Yp �-1---e---------No. Compartments ------------ Distance ---- ---- _ Distance to nearest: Well.-._____:_ ---------------Foundation-----/-O______,__=..._Prop, Line------1 ----_-------- LEACHING LINE [ No. of Lines._____,_______._._;-_.,__._.Length of each line--------- p_„ ___,----Total Length. --------___________ . t D' Box___------Type Filter Material_- t ____.Qepth Filter Material............ _____________.-______________._-_-_a-__. Distance to nearest: Well --------------Foundation-------/4(7_/--------Property Line--------cS----------- ___ ____ T [, Depth_.__._ __._i aaater- 7___x Number_____________ ______ _______ Rocck/Filled Yes ( No E] r Water Table Depth--------------- ----/-------------------- -----Rock Size-----�.---'A” ti - - Distance to nearest: Well.Q.____ �__ --------------------Foundation._.__1��_�__'` _ Prop.-Line_____ f REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------------------- -----Date- ---- ----- ----------------------------------- Septic ------ ---`-------- .----------Septic Tank (Specify Requirements)------------------=----------------------------------=--------------------------- ----------------------------------- - --=----- -=—R- Disposal Field(Specify Requirements)---------------------- --------------------------------------------------------------------- ----- €k -------------- - -------------- ------------------ ---------------------- --- ------- --------------------- ------------- -------------------------------------- --------,------------------------------------ --- - ------------- (Draw existing and required addition on reverse side) j 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: "I certify that in the performance of'the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation Jaws .of California." Signed------------------ ------------------------- ------- -------- --- - -----Owner _ By-. ------------------ - --------------------- Title - J - t i '(If other than owner) FO EPARTMENT USE ONLY ' APPLICATION ACCEPTED BY----- = = DATE --- --------- ------------------ +: DIVISION OF LAND NUMBER------------------------ -----------------------------------DATE--------------------------------------------- ADDITIONAL ---------- 'ADDITIONAL COMMENTS----------------- ------------- ------- ------- ----------------------------------•--------------------------------------------------------- ---------- ----------------------------------------------- -------------------------------=--------- ------------ --- ----- --------- ----- ------=-----=- ----------- ------------ ---- -- --- ----------------------------------- ---------------------"=----------------- ------"----------------- ---------- --- -------- ------------------------- ------------------------------------------------------------------ ------------------------ / //'77 .. Final Inspection b C.� �. --------------------------Date-----�--- ------------------------------------- EH - ----- ---- -------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M