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FOR OFFICE USE: rFOR OFFICE USE: APPLICATION MR SANITATION PERMIT 4- 7�� y Permit No----------------------- - �------- -------�� ---------� --�------- -- -- (Complete�in Triplicate) Date Issued : 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 County Ordinance No. 549 and existing Rules and Regulations: aogAyr4 / � C - -------CENSUS TRACT-------------------------------- JOB ADDRESS/LOCATION------------------ ------- - - y Phone._ ---- Owner's Name.----. ---- ---------------------------------------- --- L-. Address-.-.------- Ci p - Contractor s Name__-.__-.._________________- ---.License #----------- ----------------Phone--- ------------------------- Contractor's ------------- --------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------------- ---------- �r ------ AL-Garbage e Grinder...>_.___ --Lot Si -------- ------- Number of living units:--------- of bedrooms._. g Private Water Supply: Public System and name----------------- ---------- -- ------------------------------=---------------------------------- ---------- Character of soil to a depth of 3 feet: Sand ❑,r=Silt❑ Clay.❑, Beat❑. r Sandy Loam ❑ Clay Loam ❑ 1 Hardpan.E] Adobe Fill Material—'_- If yes, typen*.___--------------------------- V (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.--..--------------------- -T Capacity--------------------- e--------------�-----Material--------------------------No. Compartments----------------------------------- Distance to nearest: Well ----------------------------- -------------Foundation-------------------------.Prop. Line_.------------------------ LEACHINGLINE [ ] No. of Lines-----------------------------Length of-each line------------ --------------------Total Length ---------------------- ---------------- .�- Depth Filter Material------------------ 'D' Box_______---Type Filter Material____________. - ------------------------------------------- Distance,to nearest: Well---------------- -----Foundation----------------------------Property Line---------------------------------- SEEPAGE PIT [ ] Depth----------------Diameter_.------------------Number-------------------------------- Rock Filled Yes ❑ No == __ _Rock Size-- --------- Water Table Depth----____—_,------ " Distance to nearest: Well--------------------------------------------Foundation------------------------- Prop. Line------------------------- - REPAIR/ADDITION (Prev. Sanitation Permit#---- -__ Date_- 1 Septic Tank (Specify Requirements)--__..._-. �'4' r=te Disposal Field (Specify Requirements)---------- ----------- __ - --------------------------------- ------------------------ ----------- (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 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 wh' h this permit is issued, I shall not employ any person in such manner as to become sub' t to W cman s p ation I of California." Signed--- /- f Owner ____ -----Title------- ------------ --------- ------------- ------------- - -- ----------- --------------------- (If other than owner) FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY-- -- -----------------------------DATE .--- --- DIVISION OF LAND NUMBER---------------- ------------------------- DATE ------------------------------------ ---------- ---------------------------------------------------- ADDITIONAL COMMENTS--------------------------- ----------- ---------- ------------------------ -------------------------� -- ----I------- ------------------------------------------------------ Final Ins p ection bY= --------- �� �- --� --------pate.-��.-'��t �7---� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M