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Ar.' - FOR OFFICE OSE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No....____ -------- --- pp --------- This Permit Expires 1 Year From Date Issued Date Issued-_d-_�fn_?_.7 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: ' U 1 U J JOB ADDRESS/LOC N__-._. _ __-CENSUS TRACT-------------------- ------------------------------------------------ Owner's Name. ------------------ - - ---------------------------- ------------ --- -- ---- - -------.Phone Address---..-- p - - ------ ---- ----- ----------- ------------ City . Contractor's Name---- _ ___ _____ __ __ _ _ G -- ---- -- ---- o------License #__32$- Phone------------------- ----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ _ Motel ❑ Other_ ---�------------------ Number of living units:------/--------Number of bedrooms__-_3___Garbage Grinder .-_-_____Lot Size.---_._.-.___.� Water Supply: Public System and name______________________ Private -------------------------------------------------------- - --- ------------------------------------- Character of soil to a depth of 3 feet: Sand ❑ Sift❑ Clay ❑ Peat ❑ Sandy-Loam ❑ Clay Loam ❑ Hardpan g Adobe ❑ Fill Material----- _-----If yes, type------------------- plan, showing size of lot, location of system n relation to wells, buildings, etc, must be placed on reverse side.) # NEW INSTALLATION: (No septic tank or se age pit permitted if public sew`eF is avall`crble'within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK }" y "19Size ( l [ _ = /_c = . - n- - Liquid Depth.-----F --- -- --- -- ` Capacity_.1-4-U------ -Type �Mater-iat "-�-�-- -----No. G_ampartments------_')_-------- ---- --- / Distance to neat: Well---- U- � _--I 67 ____._.Prop. Line___ ��_ -- -------- ---- LEACHING LINE [ ] No. of Lines-----------------------------Length of each line-------L'---- ->�' - --------.Total Length.-- �--------- FT' �- ��- - -------- - - 'D' Box----- ....._Type Filter Material-- S ��__-Depth Filter Material.---___j__47 ------------------------------------ Distance to nearest: Well-------1:.o_E?,_ Foundation----.-_1-12.- Property Line----------- _ ------- SEEPAGE PIT j Depth- `.��Diameter__� __-----Number_____-_c3-------------------- Rock Filled Yes �o ❑ Q ; Water Table Depth.r= /b -------------------------Rock Size- 4�_-/'.3 Distance to nearest: Well ._------I_S-Q-- _ ----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 aid 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 pe mance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject f fork an's Compensation laws of California." Signed ------------- ---------- Owner -- ----- - ------------------------ By-------------- - Title---� ----------------------------------- r ---------- '` (If other than owner) F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------;Dr�_F_. -------- DATE.{ -1 --------------------------- ISION OF LAND NUMBER DATE. ----------------- -- --------------------------------------------- --------------- DITIONAL COMMENTS_____ _ -------------------------------------------- ---------------------------------------------------------------------------------------------------------- - -------------------------------------------------- -------------------------------- ---- Final Inspection by-------- ------------ - ------- -----------------.Date----- --- - ------------------------------------ - -------------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M