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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------------------------- (Complete in Triplicate) Permit No._ 7�_- Date Issued_.__: -_717 --------------------------------------------------------- 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 County Ordi !Q_a No. 549-and existing Rules and Regulations: JOB ADDRESS/LO ION--- - + ..-------- - -- --`-- ----_7� _ -----.CENSUS TRACT------------------ Owner's Name.---- ------- -------------------- --------------- -------- ---------------Phone O �1Q CityJ--c Zip Contractor's Na e- f. –s�- - lr---- :--------- -� �?.License #_> -z_ -Phone------------------------ -- ---- Installation will serve: Residence�Apartment House ❑ Co merc'01 ❑ Trailer Court ❑ -- --�--- Motel ❑ Other___ A -- --------- - 1 Number of living units______ _________Number of,bedrooms----�___Garbage Grinder-------------Lot Size----- _ ___....__._. -"'--------- ------ __.___O Water Supply: Public System sand-nam-el------,---3= _- - ---- ---- ----- ---- ---- ---------- ----------------------- ---------------------------Private . Character of soil to a depth of 3 feet: Sand E] Silt E] Clay E] Peat ❑ _Sandy Loam E] Clay Loam ❑ Hardpan Adobe ❑ Fill Material__.._- -----If yes, type________________________________ 1 (Plot plan, showing size of lot, location of sysTem 'in-Tel Urii5b to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank orxsseee age"pit permitte if public sewer-is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK] , Size_ _� _!.- - Y"i l ,1 x 1 --- ----- ----------------------------Liquid Depth-- --------- ------ CapacityJ Z ----TYPe - --------------------Material__d-Erk --------No. Compartments - ---'�"--------- -- -------- { Distance to nearest: Well------ Foundation-----J_k_�------Prop. Line----- l__ --------- LEACHING LINE jNo.'of:Lines. __--------------_Length of,each line--------_i_b__ -------Total Length------ ?_ ____.________- ] D' Box---- Fit#er Material__._ _�� ---Depth Filter Material------- --r�--.------------------------------------------- Distanceto nearest: Well_- –_Co�J__ 'Foundation__-_--_ --.--Proper Line------`r ___ -_---._- SEEPAGE PIT [1 �.. Depth__ : Diameter___._��_ _____Number---_Y__=__� _____-__ Rock Filled Yes[�No -- Water Table Depth--------100-------------------------------Rock Size---1�V----�--3----------------------- Distance to nearest: Well__t1 __—e-__ Foundation---.--_.} _ '_.Prop. Line_______'-(� REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------------------------------} SepticTank (Specify Requirements)----------- -------------- ------------------------------------------------------------------- -------- ----------------------------------------- ------- DisposalField (Specify Requirements)--------- ------------ -- ---------------------- ----------------------------------------------------------------------------------------------------- ---------------------------------------------- --------- ---------------------------------- (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 San 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 rkman's Compensation laws of California." Signed- ----- --- -- ---- .- -------- - _ I Owner° BY----------- - ----- -------------------Title--- ----------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ---------------------------------------------------------- DATE.-.-- ----- ---- DIVISION OF LAND NUMBER---------------------- ---------------------------------------DATE --------------- ------ ADDITIONAL COMMENTS------------------------------------ ---------------------------------------------------------------- ------- ---- --- ------------------- --------------------------------- --------------- - ---------------- ------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- - ------- ------------------------------------------- ------------------------------------------- -------- - ------------------------- FinalInspection by:------------ --- -----------------------------------------------------------------------------------Date L -------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M