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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No...77-_. � ---- -- ---------- - This Permit Expires I Year From Date Issued Date Issued- ' S_ � 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...----._---Z-z-- --�-w Owner's Name..__--0- . - --_-.- ------ -------------- ---�----------CENSUS TRACT----------- --- fe Addressz - - ------------- -------- ----------- - ------ ----- ----- --- ---- ------ ---.Phone ------------ ------------ ----- ------------ -----;- -- ---------- --.---City----- ` ' `�-- --- Zi --------------------- lei Contractor's Name-_- -_- - ---- ---- - - - -- - --------- -License #--3Zk>_Z_6----Phone------ ---------- Insta ation will serve: Residence 2!r Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑. Other--- --------------- -------- Number ------Number of living units ---- --------Number.of bedrooms_ - - _ dr age Grinde ------.----lot 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 2r 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 [ I SEPTIC TANK [ l Size-----------------------------------------------------------Liquid Depth ------------------_-_-----� Capacity---------------------TYPe.----------------------Material--------------------------No. Compartments.------------------------ --------- Distance Distance to nearest: Well_------------_--------------------------------------------Foundation - Prop. Line ----------- ------- LEACHING LINT: [ ] No. of Lines---------------------------- Length of each line.-----------------------------.Total Length ----------------- -------------------- 'D' Box---------.--Type Filter Material--------------------Depth Filter Material--------------------------------------------------------------- - Distance to nearest: Well-----------------------------Foundation----.......-----------------Property Line.-..---.----_ ---------------------- SEEPAGE PIT [ I Depth_ -----------.Diameter--------------------Number-----.------ ---- =`---- Rock Filled Yes ❑ No ❑ . Water Table Depth- ----------------------------------------------------- Rock Size J Distance to nearest: Well---------- -----------•--------------------Foundation----------- ------ Prop. Line.------------------ Q REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date-----------------.----.-- Septic Tank (Specify Requirements)------------ ------- ----------- ------------------------------------------ -------------------------------------------------------------------------- Disposal Field (Specify Requirements)-.---- dL- -. . .... �' ------------------------------------------- -� ,�. ------------------------------------------ --------- ---- -------------------- ----------------------- ---- (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: K "I certify that in the performance of the work for which this permit is issued, 1 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) -- -------------------------------------- O DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - t - -----------DATE._/0---- DIVISION OF LAND NUMBER-------------------------- ------------------------------------------ - -- -------------------- --------------- ------------.DATE .------- IONAL COMMENTS---------------------------- - --------------- ----------- ------------------------------------------------- -------- ------------ ------------------ ------------- ---------------- ------------------------------------------------------------------------------------------------ - ------ - -- -------- ---- ---- ------ ------------------------------------------------------------ Final Inspection by = ---- - -- - - b/ �� - - - -------- -----------Date i ---------------------------- - 4 EH l3 2A SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M