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FOR OFFICE USE: FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT ..... ........ .. p (Complete in Triplicate) Permit No..�,!-.:)/....-- ------------------------ Date Issued a� = 3 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.. .�L! .. WCENSUS TRACT................:....... ... C f�l �t�z!j 2�r.{ i • Owner's Name _ .- - ---- --------- ------ _-Phone ! _t��1..��..--- _ Address............................1- .- ------- .---- City.- -------- -- ---zip--- --------- -------- Contractor's Name--........ .. ............ .. _ ....... ..........License #.;S y3-- -----Phone �sG`9�D7- Installation will serve, Residence ❑ Apartment House ❑ Commercial X Trailer Court ❑ Motel ❑ Other----------- ----------- -----------_------- Number of living units:__..... ---.Number of bedrooms....3.. ..Garbage Grinder----.------.Loi Size......... ..---...... . ...---------- .__........ -- Water Supply: Public System and name_ ............... ----.----- --------- -----------------Private 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.) 4 NEIN INSTALLATION: (No septic tank or seepage pit permitted if p li sewer is available within 200 feet,] ,r U PACKAGE TREATMENT [ ] SEPTIC TANK ize ....... !.- - -- ----- ---------_.._.------------Liquid Depth....----.---.---.- C5- Copacity.1>6_6-------Type-- .....Mate-ria - -------------------No. Compartments ------_ -----...- ----- ---J' Distance to nearest: Well-------� --r ... . .. ..... ... oundation......1 -- "... ...Prop. L_ine._� _. ....----.... LEACHING LINE No. of Lines + Y ---� - --------------Len f e -�--.....----- ----Total Length .��..Q.:�......- - --------- it 'D' Box..._L.___.�.Type Filter Materia ...... .... .... Depth F' rial-- ---.lopp... ---------------- -- -------- ...... Distance to nearest: Well_..._............... tion.---- t.-........Property Line....--.t..... - ......... SEEPAGE PIT [ 3 Depth.- .. ..-- Diameter--------------------Number Rock Filled Yes ❑ No ❑ Water Table Depth------------ -- --------- - ................. ...Rock Size...------ ..._..... .. -------------- Distance to nearest: Well.-.......... .. . ---- ndation...-... ..................Prop. Line----------.............. --'� REPAIR/ADDITION IPrev. Sanitation Permit#----------------- ---- ------- ...... cite-------------------------.....- --------------} Septic Tank (Specify Requirements)...... ._ -- ----------------------------------- ........... Field (Specify RequiremeQandReg . ----------------- ------------------- -----------.. . .... ----------------------- - ----- ------------- xist g and required addition on reverse side) I hereby certify that I have prepalicati n and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rug ions 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 Workman's Compensation lows of California." Signed ...................... ---------- _ - ----- ---------------- -----.....-- Owner By.......... -`----- ------------- ............ Title.__.-.. ------ - -------........ --...------....- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..--- .--A ........- w1 ~, ------- - ------------ - --� --- ------------- --........_DATE -- -------3..-..-- ----�- - DIVISION OF LAND NUMBER. ------- DATE .....-- -- - ADDITIONAL COMMENTS.......--.-------- ---------------------- ------ -------------- -------------------------------------------------------- I----- ---- ---------_...... ...------ . ........ ....... .... ---------------------------------- -------------------- ----------------------------------- ----------------------- --•-- ------- Final Inspection by----------- ----- --------- --------- - ----Date.--- ----- --- ------ ----- ------ -- ----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M