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FOR OFFICE USE: / APPLICATION FOR SANITATION PERMIT FOR OFFICE USE- '7 (Complete in Triplicate) Permit No7i __ _._____ Date Issuedla�.-#.-2� --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit'torconstruct and install the work herein described. This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: 4-W-&-7- - -- l - w_. JOB ADDRESS/LOCATION.---.-` J�J� ----------�°D— ---J-Z------------- -- - - ---------CENSUS TRAC -- - '--. Owner's Name n --------- : - Phone--��----7-_5_�S� f 133 / Address 7- --- 1. - Cit "`�'` "`� Zip - - Contractor's Name___ _ ._ 3�_ __ J 41— "---License #_-7052 l.-----Phone__ -3- 4 Installation will. serve: Residence [j`Apartment House ❑ Commercial ❑ Trailer Court ❑ a I Motel F7 Other--------------------------- Number of living units:--/----------Number of bedrooms'_-3----Garbage Grinder:4__:_..__Lot Size__® `-" [ Water Supply: Public System and name----- -_- -.-:_.:->----------------------- ------------------ ------- '-------------------------------------Privatecu Character of soil to a depth of 3 feet: : Sand E] Silt 0 Clay ❑ Peat 0 Sarrdy Loam (Clay Loam ❑ Hardpan ❑ Adobe [] 3 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 pub!'ic sewer is a'✓�aliable within 200 feet,) PACKAGE TREATMENT [ ] ' SEPTIC TANK � ' Liquid Depth ___ ____ ___ Size" - ---------------------------------------_�,.,... ---------------- Distance to nearest:�Well=`-.----- :_ Material- --------------`---=r--No. Compartments--.---------_-----------------_ - f Capacity.---------------=------TYPe---- -- == :_:Foundation .ter° ____._,.Prop. Line---------------------------- LEACHING LINE [ ] Na. of Lines.;_- ___'_______________:_.length of each line._ ;_.._:_.Total Length.!,--------,_____________________ _l 1 y. D' Box----.-------Type Filter Material:__I- __ ' DepthFilter Material. '____._ { Distancere .to nearest: Well-- -------- -------------Foundation_.___':__-___-_ __:_"___; l?roperty Lin � e SEEPAGE PIT [ ] Depth----------------Diameter-------------- __"_Number__---____ _ f, Rock Filled Yes ❑ No . _ _ •'�� . _ Rock Size_:_ # Water Table Depth. ---------------------------- -------- :;�.--------`-------------- Distance-to nearest: Well------------------------------=-----,------Foundation- -'Prop. Line_----------------------:---. [ --------- REPAIR/ADDITION Prev. Sanitation Permit#"_"_._�----�-. -;--: ' . j - -- ---- - ' ------ ----- --------- � - ----------- Septic Tank {Specify Requirements)-------------{.----- .---_.;.--- _--,~----. - Disposal Field (Specify Requirements)_________________ ___ "_r--_---:_________________ - ----- ---- -----=--------------------------------------------------�a-'-- �-__-�- ......-- .--- :-------� ------------ ---------------------------- ----------------------------------------------------- -------------------- --------------------------- -------------------------------------------------------------------------------------------------- --------------------------- (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 n Ordinances, State Laws, and Rules-and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: I "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in'such manner as to become subject to Workman's Compensation laws.of California." Signed----- >< -- ----------=--------------- ---------------------Owner By `^~1- ------------------------------------ Title------ 1 � -e-------------------------- (If other than owner) s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----.------ -- DIVISION OF LAND NUMBER.. ---- ---- ------------------- --- DATE.----------------------------------- ADDITIONALCOMMENTS- ---- ---------- --- -'-- ------------• -------------------------------------------------------- ---- ------------------------- --- ---------------------------------- a ---------------------------------------------------------- - -- ----------------------------------------------------------------- ------------------------------------------------------- ----------- - --------------------------------------- --- 1 -- Final Inspection by:------ = _ ---- -- r Date...-f� "- - - - --- ------ EH 13 24 SAN J UIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M