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FOR OFFICE USE: FOR jOFFI+;_t USE: •�' APPLICATION FOR SANITATION PERMIT Permit No.. ............... 11....................................... (Complete in Triplicate) ............................ ......... .................... I � . Date issued.�-?-.y.':?2 ....................................................... 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 ance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION....:. ....... J ........ _ ....__.. ...--•------ .....CENSUS TRACT ............ -•................. Owner's Name....... ................ :.. . . Phone...... 8�.. ,/ a.0 .... .. ... . ..•.......1.' .. .................Zip._.: i Address.......-�y.. - ...�r..t.1.. .. ......_. . City . _ _ l . Phone.. .& f `........�...........................License # 3 I-..... :s.'a6 ..._.... Contractor's Name ....................... ........ Installation will serve: Residence g -Apartment House ❑ Commercial ❑ Trailer Court ❑' Motel ❑ Other; ........... ...-^ ... ..� _ _._ _ Number of living units: .... .�.;..::..Number of bedrooms ... 02.._..Gorbage Grinder__ . - ...Lot Size.�0 .,K�t!.d..- .----=•_•.•.----.--. . Water Supply: Public System and name ................................. :.. t_......_..-•----....----....._ ............... Oat.. ............ Private El Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ ; 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 on reverse side.) NEW .INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK [ 1 Size ...... :........................... •--....:.................. Liquid Depth ... ::-.................... Ci i Capacity ... _._............ --.Type ............. ......Material. -•------...........-•----No. Compartments......:..... Distance to nearest: Well :.--------- .......................... :.. Foundation .........................Prop. Line... ............... ... LEACHINGLINE [ J No, of Lines ............ ................. Length,of;each line ............................... Length ...................................... 'D' Box ........ .... Type Filter Material....................Depth Filter Materiol... ....... ...................................... _........... I Distance to nearest: Well..:") .....................Foundation.___.._.......__ -_•-_-•••-••Property Line._.........-.. -- ..•----.---••••-- � . . Rock Filled Yes No ❑ SEEPAGE PIT (} Depth.................Diameter......!.r:~-......Number.::----•-:....:_:.--------•-•• .. - Q � c Water Table Depth.__.' ........................... ............Rock Size-------------- ----- ....:............ Distance to nearest: Well ............. ........ ........... ........... Foundation ......... ................. Prop, Line............................ REPAIR/ADDITION (Prev. Sanitation Permit--#. ............ ....................................... Date........__..- .----..............__..._.... Septic Tank (Specify Requirements).. . ............. ...:................................ Disposal Field (Specify Requirementsl.- .~.. .... .......... ............................................... ......................... ................ I .......... ........ ..._................... .............. ................................... .. ................. .................................. I ................ ............ ... (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 San Joaquin Local Health District, Home owner or licensed agents Ordinances, State Laws, and Rulas and Regulations of the signature certifies the following: "1 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 m n's �evmpensa on laws of California.';. I Signed ................. w Owner ••W �" r t,.:....... ................. k By ........................................ ....r.J -./'� ....Title..... E (If other than owner) FOR.DEPART)4NT USE ONLY APPLICATION ACCEPTED BY.::......_ ....... ..........cam``..... .... ......... -•------..DATE ................ ..f.._........._..-........ DIVISION OF LAND NUMBER ........ .-....DATE ............. ... ADDITIONAL COMMENTS_. 3U - cl< ...... ................. •.....................................................---........................................................... ........................ ................................................ ...-•-- .....•- . .. _ Dat E. Final Inspection b } FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fa 21677 REV. 7/76 7M