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l FOR'OFFICE USE: tFOR OFFICE USE: :APPLICATION FOR SANITATION PERMIT �! --------------------------------- Permit No.. . (Complete in Triplicate) --------------- ----------------------------------- - r ..�- ------------------------------------------_------------- This Permit Expires 1 Year From Date Issued 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 -- JOB ADDRESS/LOCATION._...-_ � f J`'� CENSUS TRACT Owner's Name --- ---------------- ---- ---- ------------------------- �---------------- -----Phone:---------------- --- -- ------------- �r � � �� City ". tm4 �.��Zi - -` Address = z - ------- Contractor's Name-------- �� l�z= E^ License #. �_ Z�r ._ Phone---------------------------------- Installation will serve; Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ot er----------------------------------- --- ----- Number of living units------- ------Number of bedrooms__ ___--_Garbage Grinder------------Lot Size------- -- -- --------------------------/ Water Supply: Public System and name---------------- --- ----------------7 . __ ------------------------------------Private :L`1 Character of soil to a depth of 3 feet; Sand E] Silt❑ Clay ❑ E]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. MIust be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT _-----Liquid Depth. [ I SEPTIC TANK [ ] Size----------------' -- ------------------------------ -----T Type YP - Material--------;-----------------No. Compartments-------- ----------------- ---- Distance to nearest: Wel.l--------------------------------------------- Foundation--------------------------Prop. Line--- LEACHING LINE [ ] No:"-of Lines---------------------------- Length of each ling -.-.---.-Total .Length.__._____.,--------------------- _-_____.,__ , YP .-Depth Filter Material- '--------- ---- ------------------------- ----------- D;'Box.__.____- _T a Filter Material..__.____..____._..De t - Distance to nearest: Well----------------------------Foundation__- _.Property Line_._________._.---___---__.--_ _-..�_. .SEEPAGE PIT I I Depth-----------------Diameter--------------------Number------------------------------- _Rack Filled Yes ❑ No ❑\,,I� Water Table Depth----------------------------------------------------- --Rock Size-----=---------=--------`--__ _- ------- ---------- Distdnce.to nearest: Well---------------------------------------------Foundation.-=-------------- =------Prop. Line--------------.------------. . REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date'-----------:-,,--- --n-__�---:- -----) Septic Tank (Specify Requirements)--------------- --=-------------------- - ; ', f' —_ - -- ---------------------------------------- _ Disposal Field(Specify Requirements)--- � �-- --------------------------------------- -.---- F�, 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 accordanc&iwith San Joaquin County Ordinances, State Laws, and I 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 anner-as to become subject to Workman's Cornpern-sation laws of California.- Signed----------------------------- alifornia."Signed----------------------------- -- - ----------- ----- - ------ --- - ------ --Owner r BY Title' -------------------------------------- ---- ---- - - (If other than owner) FOR DE RTMENT USE ONLY I IF APPLICATION ACCEPTED BY---------- - 1-- - -------- ---- ---------------------------------------------------------DATEO)-'�!`-le--------------------------- DIVISION OF LAND NUMBER------------------ ---------- ------------ -----------------------.DATE..------------------------------ ------ - ---------- - - ------------------ ADDITIONALCOMMENTS--------- ------------------------------------------------------------------------=------------- ---------------------------------------- --77 - ------------------- Final --Final Inspection by ---Date.-- ......`y--- -- ---------------- EH - --- ----EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.7/76 3M