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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------- A Permit No..7�- {Complete in jTriplicatel 'A Date Issued_.._-.`�".� -�� _________________________________________________________ This Permit Expires 1 Year From Date Issued ----------- 1 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: ZJOB ADDRESS/LOCATION = 1 � � .. -- ----- ---- ---CENSUS TRACT------- _------------ Owner's Name - ` e'----------- = - - ------ -------------- Phone--------------- ---- ... Address---------------------- - ---- e .� - City -" Zip Contractor's Name ------.--- ---- License : ka Phone Installation will serve: Residence [ Afpartment House.❑ Commercial ❑ ;Trailer Court ❑ - s. .. .r.-_. .3..Motel ❑ Other--- ----- --------------- ---------------- Number of living-units:_._ t_._.,Number of-bedrooms___ '____Garbage Grinder------------- _...__.________ S - -- ..___._��-�.....�-- -- - - Water Supply: Public System and name----'------------------------- ---- -----------------=--- ------------------ -1------'-- - - Private LJ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat El Sandy Loam LTJ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material_---------If yes, type...______________________.___._ i (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-ii cvaifable]within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAMC [']' Size------ -- --- -- --"_-""_ _-Liquid Depth-:_____. Cj Capacity--------------------==Type -- . . a i�l------:_.-=-------____:+_No. Compartments = =- Distance to nearest: Well.;.._.____.,,_ ...._._.....:........ ...'_,__Foundation--------------------------/.Prop. Line-------------.--------.----. fa r i ['] o. of Lines- ----- ------ --- - -- Length of"each line fi i - - Total Length.-�-•_a--,------------------: -- LEACHING LINE N = D' Box--,---------Type Filter Material --------- " ._..DeptK!7ter Material---------------------------- ------- Distance to nearest: Well_______________ ______'._____Foundation____-___j-_-_._____________Property Line.______.____.__.________ _ .. SEEPAGE PIT [ ] Depth________________Diameter.;.____I----------__Number__-. _____ Rock Filled . Yes ❑ No ❑ �:�:�-------._ { s ` � _,Found#Size_ } Distance to nearest: Well------- -- ----------- on_-: Water Table De th_ Rock - - - 4 1 -----------------------Prop. Line-------------------------- REPAIR/ADDITION ]Prev. Sanitation :=-' ------------------------- --__:Date----------- -------_ ---- ---------------- -) Septic Tank (Specify Requirements)..---- --------------------------- r --------------------------------------- - = Dis al Field Specify,Requirements}._.._. . ._ -- —� ----- . Y - ----------------- -- �� ---� (Draw exisfin and required addi________-------------------------------------------------- " ---- - - =---- ----------- g q tion oreverse ide) 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: 1 "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." _ { t Signed--------=----------- ----------- i Owner , ," " . . BY --------- =--- ----------- � - ) �`'�` Title , --- ------------- 4 ---- ------- ,' (If other than,owner s " TORMEPARTMENT USE ONLY' f k. APPLICATION ACCEPTED BY- --- > -- ' -- -- --=-- �-----------------------------------DATE. --------------- --- - - DIVISION OF LAND NUMBER------ ------- ------- - --------- - DATE-=-------------=---- ' ----- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------ ----------------------=------------------------- ------------------------------------ ----------------- --- ---------------------------------- ------- --------------------------------------____._-----._ ------- _ _._______.________.____.______________________________________________._____.__.__--_ % Final Inspection by =------------------- ----- bate + � �_.. :----. - ... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M