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FOR OFFICE USE: -J FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No ...�f- 7 (Complete in Triplicate) --------------------------------------- -----•.....- Date Issued.."...'...... _- 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: I I / CENSUS TRACT.......... JOB ADDRESS/LOCATIO ,l- Owner's Name_... City----...--- -------- ------ ---- --- --------Zi .......----------------- Address -- -._... ------- Address-----..._ .............. Vol License o Contractor's Name------- -- --- �-.. ...... ........License #- �.- � Phone.. .... ------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-.__ ........ :............................ 1 Number of living units:....... _Number of bedrooms.---fl,...Garbage Grinder.....-------Lot Size------- ------ --------Private Water Supply: Public System and name._.:_.. ----- --- --------- ........ -- - ------,- ❑ Character of soil to a depth of 3 feet: Sand E-1Silt ElClay ❑ Peat ElSandy Loam Clay Loam El 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 [ ] Size ... -------------Liquid Depth... -------------- Capacity------ TYPe--•------------- ---- Material............ --- _...No. Compartments-------- .......... .---........ 6 Ic e Distance to nearest: Well.. --------Foundation...._.._ . _.. . . Prop. Line [i LEACHING LINE [ 1 No. of Lines - ----------------• .......Length of each line.--------------- ------ Total Length --- ------------------ r...--- Depth Filter Material------------------- --------••------- • 'D' Box._..........Type Filter Mater.iaL_.. - ----- �-� p Property Line_.". ......... Distance to nearest: Well-_--- ..-.-..Foundation---------------------- -- P Y Rock Filled Yes ❑ No ❑ SEEPAGE PIT [ ] P .-...Number.,-. ---- Depth....._.-- -- ---Diameter------------ --- -Num er ----------•-------.... ----.Rock Size...__... -- -- �------ -------------------- I Pro Line..--- ------ ---------- Water Table Depth---••--••--••,--•- - -- --� - --- - --- ------ on.-- - -- ---- .. ----- p. Distance to nearest: Well------- ." ... -- . - _ .....Foun ati ! --.Date------------------------- -------------------- L ---- --- -------] REP 1R/ADDITIO rev. Sanitation Permit#-----------------"---------------- Se tit pecify Requirements)----.---... . =•... � ----• --------]- f Disposal Field (Specify Requirements)._... . = It --- �-- --- ---- - -----`�-Q-z'1.�- (Draw existing and required addition on reverse side) E 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: erson in such manner as "I certify that in the performance of the work for which this permit is issued, I shall not employ any P to become subject to Workman's Compensation laws of California." Signed-- --------------- --Owner .. - - -- ---� . Title......."....................... •--- - - By.......... ---Po� - -- -------------- (1f other than owner[ I FOR DEPARTMENT USE ONLY 71 .. ,� . - - ._._..-- APPLICATION ACCEPTED BY-..... ...-- ��- �- --- -DATE ---... ...�- - . iDATE................... ..... .. .. ...... DIVISION OF LAND NUMBER --------- ---------- --- - ---`........._. -- -- ( ADDITIONAL COMMENTS--------------- ----- - ----- -•- ---------- --- --------•-------------------- ------ --- - . Date.....---- --------- --------------�. ._.. ----- ..... ..... Final Inspection by:. - ------- •---.... "----- --------f-----•----•---------------- ----------- - -".. F35 21477 REV. 7/76 3A Efi 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT