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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FIE Permit No..._.... (Complete in Triplicate) ------------------• -------------........................ DateThis Permit Permit Expires 1 Year From Date Issued T~' 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 Rul1-0 es and Regulations..n �;/ P► 1�f� t,!' '`....... CENSUS TRACT------- - -...� JOB ADDRESS/LOCATION....'4- -'�-_- -..."f--- Owner's Name.--. _ _. .--/ .... .. .............. ..._......_...._ _. Phone._.. _ v` - 7� � Address............... W l Ci �� Zip 5 :2._ 1�. - City-, - Con'ractor's Name.._ .k. "` ..License #e _��.- -Phone �5 � I Installation will serve: Residence y Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.... ......... ---- ---------•-----•----: r A G . Number of living units:_ _.--/.-_....Number of bedrooms-_.....Garbage Grinder-_-.........Lot Size---- ..._- ------------------ - Water Supply: Public System and name.. ................. Private [ - Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy loam Cl 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 INSTAL4ATiON: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] f .� PACKAGE TREATMENT ( } SEPTIC TANK [ ] Size.... ... .. - s ----------------Liquid ` - ----- Depth-s-. �� ents....-- - - ---..... Ca acitYs1411V-------TYpelQe�� rMateial------- ------ No. mpartm ..- �. �-� Distance to nearest: Well---_.-. 1- �4.`."':.::...=-.-Foundation tet. - --.�4_TT_.``...-- Prop. Line--9,+m.-.�--------- LEACHING LINE [ ] No. of Lines ... ------------------ Length of each ena... ---- ---Total Length .. �a Type 1 , pth Filter Material......__ _.G D' Box-.. ..._....7 e Filter Material �,/ Distance to nearest: WeIL. --------------_.Foundation....._...- Property Line....._ SEEPAGE PIT [ ] Depth -- .. .....Diameter..--- ----- .......Number ----------------------------. Rock Filled Yes ❑ No E . r WaterTable Depth----- ------------•---- --------- °- -- ---------------Rock Size---- ------------------------ - ----•---- Distance to nearest: Well...-..-_-------- ------ . ....•.Foundation.........._......... -__..Prop. Line ------- ------ � REPAIR/ADDITION (Prev. Sanitation Permit#-------------------- ------------ .......... •-..Date--------------------------.- -----) Septic Tank (Specify Requirements)...... .............. .. -- -----• 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 which this permit is issued, I shall not employ any person in such manner as to become subjectWorkman's Compensation laws of California." Signed.- - •-------------- -- ----Owner By-------------------- -- ---.......Title---- ---------------._--- _.--- - -- --- r (lf other than owner). OR DEPARTMENT JJSE ONLY APPLICATION ACCEPTED BY ......... DATE ..-- ... DIVISION OF LAND NUMBER.......... .... - -------.... -------�..--------- ..._DATE--------------•.......... ... .. ...... .. ADDITIONAL COMMENTS . ..._....-- ......_ ------------- --------------- .---------- .. ... ......... ..._............. .... ... __.. - - -- -- -- --Date... - '....� - Final Inspection b 7� ras 21677 REV. 7/76 3MEH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT