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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: `G (Complete in Triplicate) Permit No.--------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued .- Application ssued ..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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION � � ------- =`------------------------- CENSUS TRACT----- _... - Owner's Name----- ------- --- - -- ----- --- ------ -Phone -- - --- -- -- - -- --- --- Address. ..------ ----------- 141. ' -----Cit y 4= Zip --------- Contractor's Name---- _ ��„ �, - �- ..License #.�.zc�'2 '-- Phone ............. Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court E]----- Motel ❑ Other......................... --------------------- Number of living units:_.... .........Number of bedrooms..._..---Garbage Grinder------------Lot Size__.. Water Supply: Public System and name_---------------_ - ---❑ - - - - - -------- --- ------- ----- - -- ------- EJ ❑ Character of soil to a depth of 3 feet: Sand Silt Clay Peat-E] S-andy- - - -- -E]- ----- - Loam Clay Loam--❑�----------- Private 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,) V.1 PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size S _-..__.Liquid Depth.__. .. ..._ Capacity -- TYPe---------------_---Material--------------------------No. Compartments----------------- Distance to nearest: Well---------------------- --- - -------- ----Foundation.._.-._ .____-.. _ - - - - -- Prop. Line-------------------------------------- LEACHING LINE [ J No. of Lines--------.....................Length of each line----._....___.._._..._ -----Total Length.._...--- -------- --- ---------------TV 'D' Box------------Type Filter Material....................Depth Filter Material:.-.__.._-- Distance to nearest: Well____________________________Foundation Property Line._..-_. --------------------- EEPAGE PIT [ ] Depth..__..__-._...-Diameter__.__._......___Number_.._..__..________________..... Rock Filled Yes ❑ No ❑ Water Table Depth------------- --- ---------------------------------------Rock Size Distance to nearest: Well..---------- -----.FoundationProp. Line - _ _ 7. REPAIR/ADDITION (Prev. Sanitation Permit#__-_.._�_ ` ��/-�j y ---------------------Date_ Septic Tank (Specify Requirements)............... Disposal Field (Specify Requirerrt,encs)-------- -- ---------------- -- --------- --- .- „ X --a_dl - - - ------ 2 (Draw exi ting and requi d adtTition o reverse side) I 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 subject to Workman's Compensation laws of California." Signed---- ------ ---- -' ------Owner BY - 6 ,C Title.-�C 4`7�c�tic-zcv (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY........ .. ...... � - ---- ------- DATE 1 DIVISION OF LAND NUMBER--------------_-_----_.---_- - ------------ -..DATE----- - ..-------------------- - - ------ ADDITIONAL COMMENTS-- - - ..._------- - -- ---- ------ - ------------------------------------------ ----------------------------- -----------------...-- -------------- --------- ---------------------------------.. .-_ _ ------------------- -------------------- --------- - --------------- -------- ----------------------------------------- -- ---------------------- ------- ------------I------_------- ------- - - -- ----------------- - Final Inspection b (-.- -- --- '� �''---� ----- --------Date .. - �� EH 13 24 SAN JOAQUfN LOCAL HEALTH DISTRICT J Fos 21677 REV. 7176 3M