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FOR OFFICE USE: s-'`^ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------------- (Ccmplete in Triplicate) Permit No...77-- _.-.__ Date Issued__ _________________________________________________________ This Permit Expires 1 Year From Date Issued (` , - r,>2- &6) -r3 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 complliigince with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION Cd h___ __ ____ __[..... ------vr� _ `---Aw ---CENSUS TRACT__./_ .-_._.__ _ Owner's Name----- - --= --- --------Phone_S(s� Address--....:�" �- - ----------- -- ---- -------- - City--------- - ----- ---- ----- --------- --- --ZIP- ------- Contractor's Name. .--- u - -- / S �� .----------------------------------- 5 ----. Installation will serve: Residence J !Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel,-F] Other----------------------------------------------- ' Number of living units-----------------Number of bedrooms_ ___.Garbage Grinder--.........lot Size....//&_4�---- ----------_-----_----_--- Water Supply: Public System and name--------------------------------------------------------------- -------------- Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ 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 seepage pit"permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK [ ] iSize-----------------------------------------------------------Liquid Depth Capacity--- ----- ---- ------Type.--------------------_Material----------------- --------No. Compartments------- ---------------- --------- Distance to nearest: Well-------------------------------------------Foundation------------------------ -Prop. Line--.- --------------------- LEACHING LINE [ ] No. of Lines---------------------------- Length of each line----.------------------------.Total Length -------------------.-----------_------ 'D' Box------------Type Filter Material--------------------Depth Filter Material-------------------.------------------------------------------ � Distance.to nearest: Well----------------------------Foundation----------------------------Property Line---------------------------- ----:� . SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number------ .i -:----- ❑ �1� ___._______ Rock Filled Yes No WaterTable Depth---------------------------------------------------- --Rock Size--------- =------------------------------------ Distance to nearest: Well..-----------------------------------------Foundation--------_--- '----------.Prop. Line___.__....__-.--______--.__ REPAIR/ADDITION (Prev. Sanitation Permit# -.---_---------Date---- ------------ -- ------ -- Septic Tank (Specify Requirements)---------------- } �= ::_ =` - ----- - ----------- -\'-- -- ----------f---------------------- ---------------- ------------ -- Disposal f Disposal Field (Specify R Irements) ------ -------------- -- ---------- ---------- -------------------- ---------------- -------------- ------------------- a --------------- r - , ---------------------------------------------------------- ---- -------------- ----------------- -------- ---- (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 Coun Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in such manner s to become subject o Workman's Compensation-laws of California.'.' Signed--------- ----- --------- --- ---- Owner ----------------------------------------- By----- Title. ,l.-- (If other than owner) O D ARTMENT USE ONLY i APPLICATION ACCEPTED BY ff l ----------------------------------------------- DATE ., --/� � DIVISION OF LAND NUMBER - DATE- --------------=----- --- ------------ -- - ADDITIONAL COMMENTS---------------------------------------------------------- --- = - ------------------------------------------------- - ------------------------ ------------- ------------------ ----- ----- ------------------------------------------------ ------- --------i n-- ---- ---------------------------------------------------------------- ---------------------------------- - Final Inspection by---------------- -!_ Date.__ _ ----� _ a ------------------------------ -------------------------- ---------------------- - - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3m