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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- ---------------•-- ------------------------- Permit (Complete in Triplicate) �9r ------------ ------------------------------------------ - ' Date Issued./-_.J/-Z� --------------- ------------------------------------ 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 Count Ordinance No. 5 and existing Rules and Regulations: JOB ADDRESS/LOCAT ION------_/__. 7�:' `" �f " = ---- ------------- --- --.CENSUS TRACT_-------- --- --------- Owner's Name. , --- -------------------------------------------- Phone---- Address _"`, - - ---- ------------------------ Ci y. Zip -- ---- --- - - -- - Contractor's.Name. �__ __ _ __________ � �-- ;.--- License # ___ PFione._____ _ Y -------------------------- Installation-will serve: Residence Apartment`Hpuse ❑: Commercial ❑ Trailer-Court-E]_'. w Motel ❑ -- Other'-------------- --- '-------- }` — t` Number of living units:------._-------Number of bedrooms_ '_. 3---Garbage-Grinder.'___:_______Lo# Size.:_..__.______ -- ------I_:____._ ._ _ !. Water Supply: Public System and name-----,:. ___. ------------ 4°!_ _:__ , --_-. ------P - ----. -Private E Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay E] Peat ❑ Sandy Loam ❑ Clay Loam E] V 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•n'reverse side:} 1 NEW INSTALLATION:` "'[No septic tank or seepage pit permitted if public sewer is'dvailable within 200 feetj' , %4 +! Capacity �' [ ] - ----'- ----- Liquid"Depth. = PACKAGE TREATMENT [ ] SEPTIC;TANK Size P y------ ----------------Type- `--------- ------Material--------------- ---No. Compartments----------=--------- `- ' Distance to nearest: WeII ` - - --------------------Foundation--=------.----- -----.'..Prop. Line-------- �`- ---- LEACHING LINE. [;] No. of Lines--------- _____----------------Length of each line:___________::___,_,__ Length=:._.:,----------------------- 'D' Box--:----- -.Type Filter Material--------------------Depth Filter Material-------------------.--------- w �.. Distance to nearest: Well---------------- ------------Foundation.-------.-_-------------,_-_Property Line-- -----------------_---_------- ,-- k SEEPAGE PIT ..- fi... [ ] Depth----------- ---Diameter--,------------ -_--Number---,------:------:------------_-_-`- Rock Filled Yes ❑i". N0 Water Table I - _De th------------------.-._ -._--'-------------=------------- Rock Size: -------------�- -------------- ------`.----- istance to nearest: Well_____ ___ ___________________________Foundation.__-- ---' -- - -.Prop. L'ne-- -------------- ----------- R EPAI R/ADDITION-(Prev. ---------REPAIR/ADDITION-(Prey. i►` Sanitation Permit-#-- _'Date____________ Septic Tank (Specify Requirements)--- ------=---- ----------- -------=---: --------:-----=------ - -=---- Disposal Field (Specify Requirements)------ -------------------- Q" i = - -------------------- ------------- -----------------=----------- ---------------------------------- -- ------:------------- {Draw existing and required addition on reverse side] I hereby certify that.1 have prepared chis application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Sari 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 I' issued, -shall not employ any person in'such manner as to become subject to. Workman's Compensatiow,laws of. California." Signed-: --------= ----------- Owner -.- ---- 1Z By_ --Title-- 'Z - --- -- (If other than"owner} �.. r :.. " FOR DEPARTMENT USE ONLY x APPLICATION ACCEPTED: BY- Gam' - ----=-------- ---°--- ------------------------ :-DATE.--- } DIVISION OF LAND NUMBER------------ ` ----- ------------------------. ------------------.. : :-' -DATE.. --- =------------------------ --- ADDITIONAL COMMENTS---------------- ------' -------:----------- i ► . . . ___________________ _________________--- Final Inspection _. ----- ---"` ",_,."�.--------- ----------- --------------Date -------- _ - .. _ .�. 1--- - 1-------------- --- EH 13 24 SAN JOA-QUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M