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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT c� �6�,a�— 7. ----------------------- (Complete in Triplicate) Permit No.._ :........... ------------------- ------------------------ P i Date Issued... 9- ---------- ....................................... ..... 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 1j1J- 0 .1/_; _L --- '��----------------------------- ------.CENSUS TRACT. Owner's Name.---------- -- --- ----- ---- -------------- ------------------------------ - Phone-------------------------------------- -- - - -- ---- Address - --- -- - ----------------CitY ��- -4 -� ZiA � '2-�---------- _r Contractor's Name-------- ------ -- � - .------License #-- ' Z -Phone--------------------- Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ot er-------------------- -------- ---------------- Number of living units:------1 ------Number of bedrooms___ ____.._Garbage Grinder-----_------Lot Size_----11�---- -- ------- .................._.._._.----- Water Supply: Public System and name--------------------------------------_--- ------p;-:-:--=4--------------------- ------------------------------------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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Z PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------ -------------------------------------Liquid Depth----------- Capacity--------------------Type-----------------------Material-- ---- -----------------No. Compartments----------------------------------- Distance to nearest: Well-------------------------------------------Foundation---.--------------- -. ---Prop. Line------------------------ 'LEACHING LINE [ ] 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 [ ] Depth___----------___Diameter--------------------Number--- --- ----__----,__--_-.------ Rock Filled Yes ❑ No ❑� Water Table Depth--------------------------- -----------------------------Rock Size----------!'-------- --------------------------- Distance to nearest: Well-------------------- --- --------------- -.Foundation `._____'_.. Prop. Line__..__...----.-..-..._.-_-. REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------.-----------Date-_.-...-------ti_.---------------------) Septic Tank (Specify Requirements)-------------------------------------- - _ Disposal Field (Specify Requirements)---- , ------------------------------------------------- ----------------------------------------- --- -------- ----------------------------- ----------- ----- (Draw existingand required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accord-once'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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in suchanner as to become subject to Workman's Co sation laws of California." Signed---------------------------- ------ --- - ---------Owner By------- -------------- ---- ---- - ---- - -- = TitEe 6� ? (if other than owner) FOR DE RTMENT USE ONLY APPLICATION ACCEPTED BY---- -t ------------------------------------------------------------------------DATE4? e. - --------------------- DIVISION OF LAND NUMBER---------------------------- - ---------------------DATE--------------- - - ADDITIONALCOMMENTS---------------------------------------------------------------------------------------- --- --- ----------------------------------------------------------------------- ------------------------------------------------ - ------------------ 7i -------- - -- Final Inspection by:-------- '...-- ....-- .-- Date...-_. -17) EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M