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11FOR OFFICE USE: FOR OFFICE U5E: V/ APPLICATION FOR SANITATION PERMIT t :� wf.��,,,., �� Permit No'.7�.y.;-/.--- --"-----•-='--•--'---------'---" '- --.... ......... (Complete in Triplicate) ` -----' Date issued_-f: 1_ .....-- •---- --- ' This Permit Expires IYear From Date Issued E Application is hereby made to.the San Joaquin Local Health District for a permit to construct andinstallthe work herein described. i This application is rriade in compliance with County Ord• once No. 549 and existing Rules and Regulations: / � .- - "---.CENSUS TRACT-----•--------- -- JOB ADDRESS/LOCATION. ............ ... .. a- - ........' " Phone.--..... ---- w :.._.... ---------- Owner's Name.. --•----- --•- -. . .-. '---- ...- - ._... Zip - : . --'-- ---------_- city Address-..---. - -- License #-� � Contractor'sName ..; II Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Motel ❑ Other_... ........ ............. ..•----•----- Number of living ue its:----_...!_----.Number of bedrooms.:--..Garbage Grindr7�_ s -=-Lot Size---/ Water Supply. PUbIIC System and name.--------.--_--:.. Character of soil to'l� depth of 3 feet: Sand E] Silt ElClay ❑ 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.) 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet] (,a PACKAGE TREATM"NT t ] SEPTIC TANK ] ] Size........ -_ '------_-------------------------- Liquid Depth.-.::.- ----------- CapacitY - TYpe Material-- ---No. Compartments-_- - ..._.. .--Foundation___ Prop. Line., . Distance to nearest: Well--------------------' --"--- •'- � LEACHING LINE *[ ] No. of Lines..:,'---- -------- ---__._.,-:Lengt.h-of_eoch;-line--.-----=-= =�= Total Length ......... ~} --- 'D' Box_ ..........Type Filter Material....................Depth Filter Materia ....-_...---...---- Distance to nearest: Well-- "--..... . --.Foundation--"--- ..--Property Line---------_----:"". �_:_- -- Rock Filled Yes SEEPAGE PIT [ ] Depth-------...__-Diameter.................---Number-------------------------------- Water Table Depth----------------- .-.-..----'--- ----------------- ❑ No - ----.Rock Size- ------- ------ ------- ----------------- -- � . . Distance to nearest: Well........_.--- .....- - Foundation.................. ......Prop. Line -"---' ' --'--' -- - ... REPAIR/ADDITION, (Prev. Sanitation Permit#---------- ---- -= .--.Date--- ----------------- ] Septic Tank (Specify Requirements]. ......_- ----- ----' •--- " _..--.--..�.......-.._� �. . �4.' - --- ------------- `... , Disposal Field (Spfecify Requirements].'------ If _- --- -- _ _ - '- mo. - .--. _. -...--. (Draw existing and required addition on reverse side) I hereby certify thiat 1 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: "1 certify that in he performance of the work for which this permit is issued, I shall not employ any person in such manner as to become sub jeic t to Workman's Compensation laws of California." r o j Owner Signed..--.. ... Title--- ---------- --------- other than owner) OR EPART NT USE ONLY DATE ..... . I APPLICATION ACCEPTED BY--.--.-"-. __ . - ---.....----DATE...--- ---' ---•..-_ ------ DIVISION OF LAND NUMBER.... -. .. ----- ADDITIONAL COMMENTS------- --------- -' "-- .. .................. ........... _------------------------ .....-.-.-.. .....---'--'--' ' ... ---- ..-._.. J1-------------- s. ' " ------------- ---------•---------_-- ------=---- --- -- --- --- q- ---- Date 'f — "----- --------- Final-Inspd'6on b �...- � F85 21677 REV. 7/76 ( EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT