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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � r _/4 17� --------- ---- -- --------------------- f (Complete in Triplicate} Permit No ____ ______ --- I Date ------------------------------ --------------------_---- This Permit Expires 1 Year From Date Issued 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 unty Orrin ce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION_ -- - .-___.____CENSUS TRACT.-_--.__-. Owner's Name ]�� --Phone l -- - Address 5 �------ 'r= "- ---- Y ZAP - --- Cit .5 Contractor's Name----------__________�__ �_ �. License #_, 7/ 3'� Phone �� '�----'Z-G�----- Installation will serve: Residence [Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------------------------- _ Number of living units:----/------Number of bedrooms----P2.---Garbage�Grinder-------.-_.Lot Size----- �.._ - + -------------------------- Water Supply: Public System and name L_ GU 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 [ ] Size-------------------------- ---- ----------------- --.------_Liquid Depth_________________ - - Capacity---------------------Type.----------------------Material--------------------------No. Compartments Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line----------------------- LEACHING LINE [ l 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____-_-_-.__-------------------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth---------------------------------------------------------Rock Size--------------- --------------- Distance to-nearest. Well-------------------------------------------Foundation-------------------------.Prop. Line--------------------------- REPAIR/ADDITION (Prev. Sanitation P mit# ____________________________ _____________ ___.Date_--__--____--_____or ______.._.____--_-) Septic Tank (Specify Requirements)-- ---- ------lr � .-__sem_.F _-_.___ ______ _ ------------------------------------ Disposal Field (Specify Requirements) c.7 - ---------------------------------- ------ ---------------------------------------------------- ------------------------------------------------------------------ ---- ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ------ --- ------- ---------------- ---------------------- (Draw existing and required addition on reverse side) 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, I shall not employ any person in such manner as to become Uecto Wor an's Compensation laws of California." Signed ------ g — 04-0. - - ------ ----. Owvner By------------------------------------ - - - 1s.2. � r ------------ --- .----- ----- --------- Title---- - -------------------------------------- ( other than owner) F DEP TM T LJSE ONLY APPLICATION ACCEPTED BY--- _DATE._�Q -��-- ----------- - --------------------- DIVISION OF LAND NUMBER_________________ --.----_--..__-.DATE.._ ___-._._..____--- ADDITIONAL COMMENTS-----------..........r_ � } -- - -- --- ------- ---------- -- - - - --------------------------------------------- . ------ ----------------------------------------- ------ ------ ------ - ------------ Final Inspection by--- ---- -- -- - Date. 1_-5 ------------- - -- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S(V REV, 7/76 3M