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FOR OFFICE USr ''� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,/ ~` ; Permit 7'.77 7_ (Complete in Triplicate) " _, Date Issued._____`._._.--7 ---------------------------------- ....... This Permit Expires 1 Year From 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: � /f _ JOB ADDRESS/LOCATION------��-__.. c(/UQQc>r l !c��C_Qe_ ------------------- ..._CENSUS TRACT- � .f-----------. Owner's Name-----� ------)1_)1? , --------------------------------------------------- ----------- --- --------Phone 3�r:4;�� _ Address---- �.P`�. -------------------------- ------City-------- -------------------------------------Zip----- ---- --- --- ----------- Contractor's Name__-6_)�a-..1<1i!w/4.cL_-- -__—Je—--------------------------License -------Phone--36-(t. ------- Installation __ - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------- ------- -- --------- / Number of living units-----------------Number of bedrooms---- Garbage Grinder------------Lot Size------l eone -- -------------.-------------..-- Water Supply: Public System and name- `- -- ------------------- _.-.�,.- ------------------- _._.-_:.--.__::— ------Private Character of soil to a depth of 3 feet: Sand ❑ RSilt❑ Clay ❑ Peat ❑ Sandy Loam�ay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material-. -------.-If yes, type_--.--..--.________________.- i {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,) r PACKAGE TREATMENT [ ] SEPTIC TANK [ ] i 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-------------------.---i------------------------------------- i Distance to nearest: Well.!--------------------------Foundation----------------------------Property Line.---------------------------------- r SEEPAGE PIT [ ] Depth.----------------Diameter--------------------Number------------------------------ Rock Filled Yes ❑ No WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance -------- ---------------------Distance to nearest: Well--------------------------------------------Foundation-_,!,-------------------- Prop. Line-.----.-----------_.__-.-_. REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------_-_-____- .Date______-_ ----------------------------------- Septic -_--_--_--- .------...________Septic Tank (Specify Requirements)---------------------------------------------------------------- . Disposal Field (Specify Requirements)---------------------- y -------------------------- - ------------------------ � --- ........ --------- .----- ------------------- -------------------------------------- - --� - - - - - - -------------------------------------------------------- ------------------------------------------ {Draw existing dhd 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: r f. "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 Work on's Compensation laws of California." Signed---------- ---- ---- ---- --- - Owner By `^ -. - ---- - ...Title------------ ~G------------------------ (If other than owner) FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY- ----------- ----- - - ---DATE DIVISION OF LAND NUMBER------------------------------ ------------------------- --------- --------------------------------DATE --- ----- ---------- ------ ADDITIONALCOMMENTS----- ---------------------- -- --------------- ----------- T--------------------------------------------------------------------------- --------------------------- ------------------------------------------------------------------- -- ----------------------------------------- ---------------- ------------------------------------------------------------------ -------------- ---------------------------------------------------------- ---------- --------------------------------------------------------------------- --------------------------------------------------------------------- ------------------------------------------- --------- - --------------------------------- ------------------------------------------ - - -- ------------- Final Inspection b ----- --- - �-- --------D- ate---------' --��----------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M