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OR OFFiCE'USE: FOR OFFICE USE: 0 i -*e� APPLICATION FOR SANITATION PERMIT �I -3 4. {Complete in Triplicate} Permit No7....'- ------------ Date Issued-_Y.„'�. v ..................................... ................... This Permit Expires 1 Year From Date Issued I i 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: JOB ADDRESS/LOCATION......... ------------- -- ---CENSUS TRACT------------------ --- Owner's Name.--- _......... ... .. - - . •--- Phone.-------- ----------- --------- Address................................... . �... ...zi ----------- -- Contractor's Name-------------- ------ii . ..... .. ....License '# Phone. + ��-.-- ' ' . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ i Motel ❑ Other-... .- --- -- Number of living units:.------r-----Number of bedrooms.......Garbage Grinder-..--...,.-.-Lot.Size..:..��._....... Water Supply: Public System and name....----_------- --------___ . .. ......... ................1 11... ................ ----------------Private>1 Character of soil to a depth of 3 feet: Sand ❑ Silt ❑'- Clciy� Peat El Sandy Loom EJ Clay Loam El Hardpan E] Adobe EJ . ,Fill Materia If---. -.- If yes, type--- .-.-. =- t f �� {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--per-mitted if public sewer is available within 200 feet,) Q r PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size------------------------------- -------- .............Liquid Depth.._::.-.- T e.............. Material---------- 1-1 � Capacity---�------------------ YP _--�, . _. . . ....,-.�.No. Compartments.----.�.•----• ---... -------- .. Distance to nearest: Well.`---------------------- --- ---- ---------Foundation.......... . .............Prop. Line.................. LEACHING LINE [ ] No. of Lines ..............'•I ------..Length of each line ------------ ............Total Length .. ._..-------------...---. ---- ----`� 0'1 'D' Box........... Type Filter Material..... ...........Depth Filter Material.- -----------------.--.-.--------------- ..------------.--------. Distance to nearest: Well................. ... . ... Foundation----___---------..-------Property Line............ _---__.........-•.-. SEEPAGE PIT ( ] Depth.......... -....Diameter.............:......Number---.---------------------------- Rock Filled Yes'[]. No❑ f Water Table Depth-------=----------_----_-- ----- ......Rock Size. ............. -------- Distance to nearest: Well.--`----------- ------ -- ------Foundation _.......Prop. Line..----------- ..__..---- REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------- -__ ----------- Rate-------•---•----- ---.---------------] Septic Tank (Specify Requirements)---". .----.- f - ....---�i --.... . ent D ........Qisposal Field (Specify m ------------------- --- .........------ ' (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 Son 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 subject to Workman's Compensation laws of California." Signed-------------------------------------------------------- ........:...... --..------- -----...Owner BY.......................--------------------- ---------------- -------------- -- -_-----Title....... ....... .......--- ... --. ........ (If other than owner) FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY-------- -- -� . .'..-- ---------------- - ---------- -------- - ----------------.-.= ..... ....DATE DIVISION OF LANA NUMBER. i..... ......... ..---- . ..... DATE ADDITIONAL COM MEN TS.XI°ZY..7 ...--- . Ia . ----------- ----- ------------- ----- x1 ------------------ -------- -------------- . .. ----------------------------•...._._....... • i ------•- Final Inspection b .................................... Date.-.` . -- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M r C��.