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T FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No---- ---------------------------------- ---------- -------- (Complete in Triplicate) --S� -�� ------------------------------ -------------------------- 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. y Ordinance No. 549 and existing Rules and Regulations- This egul=tions:This applicatidn is made in compliance with Countiw �i - ---CENSUS TRACT-------- ------------------ JOB ADDRESS/LOCATI N_=-=--__ -- �--,:-- - -- - -- - -- - Owner's Name-.. v"- -- ---------------=-------------------------- ---- ---- Phone ;: - Iz /lQ r p - ----- -4-Z"T- _yli ` L �!'"�C"' Zi Address ------ - ..... -- ----- ----�----- _ :i i - -------------- - Contractor's Name -- -- License #------ ----- -------- hone------------- "' ? �ment House. Commercial ❑ Trailer Court Installation will serve: Resiclence ]Apart ❑ i # Mofel' ❑ Other- �_} bedrooms- -f. Lot Size . Number of urnts:._�_ .- _�_-__ -Number..of bed ,�,.. --�-. living to Water Supply: Public System and name .. - .------ ----------------------------------------------.------------=------------------------------- ---------- E] ------- va Pri $ 'Hardpan [Adobe Fill aterial -k------If yes,type'- ----_- Y m ❑ ' Character of soil to a depth of 3 feet: Sand Silt Cla Peat San oarza Cla Loa -- (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 Nkithin 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ 1 Size - ' =` -----_Liquid Depth ----------'-------------- Capacity.----, Type.----:--::------------ .!I ------- ---Material r ='i:No.�Conipartments I 4,. Distance to.nearest: Well = Fountion:= i= .P.rop. Line - ---------------- d' LEACHING LINE [ [ Length of each * I T e Filter Material:_._-- -_Depth Filter s l I g ------ No. Lines- ---- --------- - --------- --�,r Material_TJaf ILen th.----- --------- ,_-_. , ] .'D Yp �. Distonce'to nearest:'Well-,------` -----. ---•------, --:Foundation:-_ -.{-.-.,-- ---:--,--- .i .� No t ? .- . -. FII _ roper ie C SEEPAGE PIT [ ] Depth-. Diametere- Number-r -------------------------- Rock ed Yes ❑.z.. . - ----------------------------- Water Table=Depth�- ----------------------------------------------------- --- -- '--- - z - --- --- , -- Rock-Size: --- ., r r Distance;to nearest: Well ri'_ Foundation- Prop. Line-- . - ---- � - - � REPAIR/ADDITION {Prey:Sanitation Permit# ---------- ----- - -_ ----Dated;-�_ ' Septic Tank (Specify Requirements) '- -- -- ----------- ----- = r `�` Disposal Field (Specify Requirements)_--- � - �------ - = ' :: - --------------- ------ --------- ----------- ;---- -.-. ------ s F y prepared {Draw existing and required addition'on reverse side} I herebycertif that 1.1 have this.application-and that the work will be done in accordance with San Joaquin County i 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 thafin the perforhiancetof'the work for which this permit is issued, .I shall riof employ any person in such ar►anner as to become subject to,Workman's Compensation: laws of California." .. - i Signed--------------- ------ '- 9- (If - --- ------. O ---- - i Tit) ` t ` other than owner) { s (t. -FOR'DEPARTMENT USE ONLY' 1 APPLICATION ACCEPTED BY:--- -- ---- - ----- = =. ATE ---- ----- -- DATE r DIVISION OF LAND NUMBER -----------------------=--- --- D - ---- ------------------------------------ ADDITIONAL COMMENTS-----=---- -------- ----- ----------------------------------------------------------------- _ _,� ' = - ---------- ---- ----- --- ----- ------------------------------------ ----- ---------------------------- - - --! - --- -CPQ/ -----•---------------------- -- ------ - Date - - Final Inspection b _ . --- ------ ----------------- Final - ---------------------------------------- --- 1 p y::= Eri 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas z�e7� REV.7f76 3M