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FOR OFFICE SE: `� } FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . 7�''S r• � (Complete in Triplicate) Permit No___ ____________S___ ---------- ---- =----- ------ 7 -------- Date Issued---- 7--7— a ----------------------___________ ----------- ____ 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 Cou Ordinance No. 549 and exist'ng Rules and Regulations: i JOB ADDRESS/LOATION...... .-------- '•�- --- --------- --- -- -- -- - ---CENSUS TRACT----------------- -- --- -- Owner's Name-- -------- -----:�� ----Phone_-------- -------- Address l � City _ Zip -- - ----------------------- O^ + --- ----License #-t1`-71-4_ -/ __Phone-_ Contractor's Name--,-� - - -- - -� ------ ----- -----------•----------- --- Installation will serve: Residence �fpartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----- ------------- - ------- --------- ----- Number of living units:_____ _____Number of bedrooms... ___Garb a Grind�erl________ _ Lot Size-_�_0_-�._�_�_V__.----------_---___ Water Supply: Public System and name----------------------------------- -- - - ------------ --- Q•Q.� (�.� --- ----------------------------------------------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,) PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size___________________________________ ____Liquid Depth________-________._ Capacity---------------------Type-----------------------Mate,rial--------------------------No. Compartments----------------------------------- V.b Distance to nearest: Well __.__-___r._______.---------------------Foundation--`--- -------------------Prop. Line---------------------------- LEACHING LINE [ ] No. of Lines-----------------------------Length of each line------------------------------Total Length._---------- --------_..__-.___.________ 'D' Box--------_---Type Filter Material-------------------- Filter Material-------------------------------------------------. Distance to nearest: Well----------------------------Foundation----------------------------Property Line----------------------_------------ SEEPAGE PIT [ ] Depth-------- -------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ C Water Table Depth---------------------------------------------------------Rock Size------------------------------------------------ �. Distance to nearest: Well_ -------------------------------Foundation--------------------------Prop. Line------------------ ---____-. REPAIR/ADDITION (Prev. Sanitation Perm #------ -------------------------------------------Date__- Septic Tank (Specify Requirements)--------- DisposalField (Specify Requirements)------ -------- ------ -------------- ------------------------------ ---- ---------------- ------•----------------------------------------------------- ------------------------------------------ - - ----------------------------------------------------------- (Draw existing and required addition on reverse side) < 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 bec me s bio to r an's JLompensation laws of California." Signed- ---- ---- ---Owner By- -------------------------- -Title---------C2.1--- �--- (If other than ow r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY Cn ---DATE.-------- - -- -7 ------------------- DIVISION OF LAND NUMBER---------------------- -------------------DATE------------------------------------------------ ADDITIONAL -------------------- -_ADDITIONAL COMMENTS----------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------_-----------------------______________________t__ --__._______-.______-____-_________--______..__________.____.:_-___-____.______-_.____ _______________________________________________ _ --- _------------------------------------------------------------------------- _______________________________________________________________________________ ____________________________________ _ _- _...__--------------------------.-------------------------------------------------------.---------------------- Final Inspection by ------------- - Date------------------------------------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M