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FOR OFFICE USE: t ! FOR OPFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------- --- -- 7- fi r— Permit No............... - - L- So (; (Complete in Triplicate) h -------------------...------------------------------------ r.> ] Date Issued----- �` �� -----------------------------------------------------__. This Permit Expires l Year From Date issued -----------_--- FA 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADQRE55/LOCA N._ 1 - ---------------...CENSUS TRACT-- ---------------- ------------ Owner's Name, Phone---------------- � City. - Zip------- Address ------------- Contractor's Name--- ----- -------------License #- ..........Phone....__-_._--___._.___.__.__.-__ -- Installation will serve: Residence Apartment House.❑ . Commercial ❑ Trailer Court 0 Motel ❑ Other---------------=------------------------------ \ Number of living units:-------r------Number of bedrooms.-.-----.Garbage Grinder------------Lot Size...-..- Water Supply: Public System and name----------------------------------------------------------- Private F11 Character of soil to a depth of 3 feet: Sand E] Silt E] Clay E] Peat E-] Sandy Loam ❑ Claym i�Loa Hardpan E] Adobe E] 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 i publicsewer is available ilable within 200 feet,) . PACKAGE TREATMENT [ ] SEPTIC TANK [Pf Size_ ._✓ 1�r..__ ' ------------------------Liquid Depth:-.-Y- __.....---------� Capacity- aWV Type- --Material ---------No. Compartments--- " ----------------------- I ` Distance to nearest: Well--------AeG'�---------------_Foundation-----Ze' ______Prop. Line... LEACHING LINE [ No. of Lines...._._.3----------------- Length of each line...----- G' --_______-Total Length.-- c;� ------------------ � i D' Box------------Type Filter Material-----. -, '-----Depth Filter Material-------L1'- --------------------------- ---------------- -- - - Fou ndations --------Property Line.... _____ _________ Distance to nearest:Well--------- �P__ EEPAGE=PIT [ Depth_- Diameter-:_--_:. .__Number_______ ________________ Rock Filled Yes 1 NeF'st Water Table Depth.........--:.-/- w-----------------------:---Rock Size -�----��--------------------- Distance to nearest: Weil__ ee�---------------Foundation...�G' ---.-.Prop. Line___r� -----_--- i 1—!,REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date----------------------------------------------) `Septic Tank (Specify Requirements)------------ ---- ---- -------------------------------------------------------- ------------------------- Disposal Field (Specify Requirements)---------- ---•_--------------------------------------------------------------------------------------------------------------------------- i { ------------ --------------------------- ---------------------------------------------------- -- -- ------------------------------------------------------------------------------------------- Y (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 i Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents I Fsignature 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 subject to Workman's Compensation laws of California." r Signed------------------------ ------- Owner If BY-------- - - - "--------- ---------Title--- C �`2------------------------------------------ (If other than owner} F11 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..___ __ _-" . ------------------------------------------------- -----DATE.., - DIVISIONOF LAND NUMBER----------- ------------------ ---------- ------------------- ---------------------------- -DATE.----------------------------------------------- i ADDITIONAL COMMENTS--------- ------------------- ----.---------------------------------------- r ------ ------------------------------------------------- ---------------------------------------------------------'-----------------------------------------------------------------........------------------ - - -------------=--------------------------------------- --------- -- --------------------------------------------------------------------------------------- i Final Inspection by:------- --- -- E ` -------------------------------------------------------------.Date. . ?----? __ _._ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21611 REV. 7/76 3M