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r FOR OFFICE USE: v FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT -------------------------------------------------------- (Complete in Triplicate) Permit No.Zf, �Ff - ----------------- This Permit Expires 1 Year From Date Issued Date Issued��-,I-'� 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/LOCAPal -11 _.._---�1,(�.__- .(�•>`• --y CENSUS TRACT__________________ Owner's Name--- --- -- -------- - --- Ph on -------------- e Address--- ----------- ty zip- ----- - - -- --- �- Contractor's Name. ------ ' � ------ / -----------------License #X -3 Phone- Installation Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ l Motel ❑ Other_______________________ ----------------------- i Number of living units:----- -----------Number of bedrooms------------Garbage Grinder------------Lot Size_/ 0 --� Water Supply: Public System and name------------------------ ------------------------------------ E]- - ----------------------------- -- - ----------------------- 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 [ l SEPTIC TANK' [ ] .. SizeLiquid Depth--------------------------- Capacity----- __.______._____- ._Capacity----- ----------- ---TYPe--- --------------,_.Material--------------------------No. Compartments--------- -------------- Distance to nearest: Well.!-------------------"=------------- ---Foundation.------------------------:Prop. Line----------------- LEACHING LINE [ J No. of Lines._-------_....................Length of each line-,.---------------------------Total Length----------------------------------------- 'D' __.____-_____------ ''D' Box__----------Type 'Filte'f'Material__ _ --------- Depth Filter Material______________ Distance to nearest: Well-------____��` _� Foundation---------------------------- Property Line-------------------- SEEPAGE PIT [ ] Depth------_- Diameter-s__--------------Number-------------------------------- Rock Filler) Yes ❑ No ❑ I Water Table Depth.------- -------- t'; ------------------------Rock Size--- ------------- ---- • - -------------- bistance to nearest: Well--- - ------------------.Foundation---------------- -- ----Prop. Line--------------------- -. REPAIR/ADDITION (Prev. Sanitation Permit#----- ------------____ , ______-_--___-.Date..___..__.___ - 1 Septic Tank (Specify Requirements)------------ --- -------- _ ---------------------- ----- Disposal Field (Specify Requirements)----.__-__ ------------- ---------- ----------------------------------------------------------------------------------------------------------------------------------------------- (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: y "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 laws of California." Signed--------- ---------------- -------- Owner ----------- BY --------------------------------- --------Title--- :2 (If other than owner) OR/DEPAR4AkENT USE ONLY k APPLICATION ACCEPTED BY------- 1Ig - ---- --- --- - ---o�^---- ------------------ -------------- DATE.------ IVISION OF LAND NUMBER DATE ---- ----- ---------- ------------ ----------------------------------------- --- ADDITIONAL COMMENTS- = --------------- � % - '�.. __ �-- - t - --------------------- __--- - --- ------------------ ---------------------------------- ------------------ ------- ------------------------------------------------- kr` � M _________________________________------ --------------- _____ ________________________________ __ ___________ Final Inspection by:_____C -- - -_.-___Date... a ------------------------------ - - �_�_z�� ----------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M