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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.. - � Date Issued--- __71.�__ ---------------______----------------------------------- This Permit Expires 1 Year From Date Issued d \ 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: s - , Q" ------ _- ----------------JOB ADDRESS/ OCATIO �-- ----- / .._-- - -Owner'•s Name------- Phone CZ�P------.city ----- ------------ Contractor's Name--'- --------------Licens --------------------------------- Address ------,---- ------Address Installation will serve: Reside ce ❑{ Apartment'House.❑ Commercial,[] -Trailer Court ❑ I Motel ❑ Other__:'.,_L � ' R t r: Number of living units:--'�___�____Nurriber of bedrooms __ Gprba e.Grinder_._. _ ..t__Lot Size ___. PP Public' System and name---=-------=---------------------- --------------------------------_" --`------- :-.,-.---.....-,._ ------Private ❑ Water Supply: Pub i _ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ ,Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ - ' . Hardpan [ Adobe E] Fill Material-___.____._If yes, type_.__.______________________.__ (Plot plan, showing size of lot, location,of system ;iIjjn relation`to wells, buildings,'e� tmust be placed on reverse side.) NEW INSTALLATION:/ (No septic tan--ko-r see a - pit permitted if public'sewer-is available within 200 feet,) PACKAGE TREATMENT. '[ ] SEPTIC TANK [ Size_7 ._�- ------------------------Liquid Depth---- ----------------- 1 Capaci#y, r�_P_ '_~. Type- M`aterial__r> z----No. Compartments-- ------------ --------- r ;�4%' 'Distance to-nearest:.Well._ --------- r _.Foundation £ .__.Prop. Line---S_------------- _____ r r.. LEACHING LINE 1No, of -------------------Length of`.each line._,_,_,` 0_ _Total Length __ _______________i__ 1 ! :!r f •� ..' Y' �i I T rD' Box.../------Type Filter Material.____ '_Depth..Filter-Material_ _______________ ___________.__.____-_.-___.__------ -Distance to nearest: Well___.�. ' Foundatian-----f4 -------Property Line__. __...___ __ SEEPAGE PIT [ i v' Depth_._ iameter. ___�� _-____Number___:___ ___.___________ / Rock Fillet! Yes No l f Water Table Depth---'------hp�'_---- l � '.. '. --Rock Size' ` - �� ------------- I Distance to nearest:'Well--------- - - ---------------Foundation.___�� r_ Prop. REPAIR/ADDITIONI(Prev. Sanitation Permit#--!__..____________________________________________Date____________.___.____._________-__-----_-----f SepticTank (Specify,Requirements)------=----------- == --------=----------------------------------- ------•----------------------------- -----------------------=---------- ------- Disposal Field (Spelcify Requirements)-- ---- --- - ---- ------------------------------------------------------------1-------------------------------------------------- --------------- --- -------------------------------------------------------- -------------------------- ----------------- (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 t and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the foil'i wing: ii "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 subiect5 to .Workman's Co enkgfid-r laws :of California.'. Signed------- =----- - I---------'------------,--- ------------------- --- 4 - - - - --- ----.-=Owner --------- ----- ------ --- ---- -- Title--- ------- --- ----- ----------------BY (if _ f I other than owners FOR DEPARTMENT USE ONLY', T APPLICATION ACCEPTED BY- --------------------------------------- DATE.---- - DIVISIONOF LANDi NUMBER------------- ---------------- --- -------------------------------- - --------------------..DATE-------- ------------------------------------- ADDITIONAL -------------------------------ADDITIONAL COMMENTS----------------- ----------------------------------------------------- --------------------------- --------------------- ---------- ------------------------------------------------------------- ----------- -------------------------------- ---------------------------- r ---------- Final Inspection by--:--:.... Date G -� '] !` EH 13 24SAN JOA UIN LOCAL HEALTH DISTRICT Fas 21e77 Rev. 7176 3M h