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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------- ------------------------- Permit (Complete in Triplicate) f- ---------------------------------------- ----------- R Date Issss ued =_��'7� 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.. !._�� - __--- � ``"��"�`J �-�f CENSUS TRACT--------------------- p ------ ----------------------- ---- "----------- Owner's Name---------- ---`P 7i- ,^r_ ------------- ----- -------------------------------------- Phone----------------------------- ----- - Address 5 7 - u`-v-� .1 Cit?' a'�� Zip Contractor's Name.----- --- o--- de - CL License #__19 2-- Phone---------------------------------- Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------------- ---- - ---- ------------ Number of living units:------j--------Number of bedrooms---,3>---Garbage Grinder------------Lot Size----.--_-_ _ ------------------------ Water Supply: Public System and name--------------------------- --------------------------------------------------- -- -------------- -----------------Private [s� Character of soil to a depth of 3 feet/ Sand E] Silt F] Clay E] Peat E]' Sandy Loam E] Clay Loam E]Hardpan V 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 see ge pit permitted if public sewer available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK [ Size ___,__ Liquid Depth_-.`7__________________� Capacity--- ;2 - -----Type - ------.-- Material__._ ......No. Compartments----------------------------------- Distance to nearest: Well------------ -°- -----------------------Foundation-------1._Q-----_.-.----Prop. Line-------Zs------------ LEACHING LINE ( ] No. of Lines--------- --------------- Length of each line___ -�______________..Total Length ___ d_._.---____.___________ .r D' Box___/------Type Filter Material----- _-_ Depth-Filter Material------- �-_-.------- ________________ _._---. - l Distance.to nearest: Well---- 0-0—_-._____.Foundation-_---1_ __�__________._Property Line-------SV_________ _----------- ------ SEEPAGE PIT [r] Depth_ _S_---Diameter------3_3---- Number------------ ---------------- Rock Filled Yes o ❑ Water Table Depth_---------------LAO----------- ---------------------Rock Size--/� -�z-- -----------------..__ r Foundation t----- `r------------- Distance to nearest: Well---------]-s'Q_________________ -�_ ..___.Prop. Line__7_____ _ REPAIR/ADDITION (Prev. Sanitation Permit#-----------..."----------------------------------Date-.--------------------------------------------) Septic Tank (Specify Requirements)-------------------------- ----- ------------------------------------------------- ------------------ -- DisposalField (Specify Requirements)_-------------------- --------------------------------------------- ---- --------------------------------------- -------------------------- ------------------------------------------------------------ -------------------------- (Draw existing and requ"—free —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: "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 a California." Signed -------------------- ---------- - --------Owner _ -- � ---------- ----------------------- -- -- - Title - -BY - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -- -- - - ---- - - ----------------------------------- -------DATE.------- --- --------_�_=1..._. DIVISIONOF LAND NUMBER --------------------------- --------------------------------- ----------- ------------DATE--- --------- ------------------- ADDITIONAL COMMENTS ---- --------------------------------------- ------------------------------------------------- ----------------------------------- ----- ------ -- ;---------------- -- Final Inspection by---------------- Q#!''G' !" - Date_--7-_-JT �--��----------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M