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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - (Complete in Triplicate) Permit ------------ ----------- ---------- ----- - --------- �� Date Issued.. ..-. ....7� --------------------- ----------- ---- .-- _...._ -- - This Permit Expires t 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 Ordinan�e No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION `.....-�. --72--- .� --------------CENSUS TRACT.-- -- - --- ----- ---- -- -- Owner's Name -� -- . =ti----- °-- ----------- -- ---- ------ --Phone--------------- - - Address. z 1 ------q--- -----Cit es ' __-Zip C� _.. Contractor's Name_--- --- �-��- - -G-_ f'� License # - - --Z�� Phone -- - - - - ---- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- --------------------------- - --------- Number of living units:-------/-------Number of bedrooms----->_�'Garbage Grinder_______-Lot Size----------1 ----:--------_._ Water Supply: Public System and name----- --------- - -- - -- -------------- ------ ----- --- - - - ------ -------------------- ------Private Character of soil to a depth of 3 feet:/ Sand E] Silt E] Clay E] Peat E] Sandy Loam EJ Clay Loam F-1Hardpan W Adobe ❑ Fill Material-- -__ -----If yes, type-------------------------------- (Plot _...._-____...............__(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,) 'V PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-------------------------------------------- -- ----'-_Liquid Depth. -- --- Capacity---------------------Type----------------- Capacity---------------------Type----------------- -----Material------ ------- ---------No. Compartments---------------------- - -------U Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line------------------------_.� LEACHING LINE [ j No. of Lines------_---------------------Length of each line____.__________________----Total Length_--------------------------____-----.__`C 'D' Box------------Type Filter Material-_-...___._____-- Depth Filter Material---------------.__..----------------------------- _------------- Distance to nearest: Well---------------------- ------Foundation----------.-----------------Property Line---------------------------- ------ SEEPAGE PIT [ ] Depth___ ---------Diameter_----------- -------Number_.__-_-____...______..____ Rock Filled Yes ❑ No Water Table Depth----------=------------ ---- ------------------------Rock Size------------- -- ----- Distance ---Distance to nearest: Well----_--,---------------------------------Foundation------------------------Prop. Line-------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#________._..___-_.___________._..___: Septic Tank (Specify Requirements)----------------- --- --- -------------------------------------------------------------------------------------- ------- --------- Disposal Field (Specify Requirements)------------------- - --- ------ -----r:— - - - - - ---------------------------------------- ---------------- ---- -- �� {�-e _------ - - - - s. - (Draw existing and requi d 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 LocalHealth District, Home owner or licensed agents signature certifies the following: r- ? "I certify that in the performance-of the-Wok for which this permit is issued, I shall nofetnploy any person in such manner as to become subject to Workman's Comp�n,sation laws of California." Signed - --../// Owner Y------------------ --------------------- ---- (If other than owner) FOR DEPARTMENT USE NLY APPLICATION�ACSCE�P�TEDY----- -. ._.... ----------- DATE DIVISION OF LAND NUMBER ---------- ----------- -------- --- - DATE - - ------ --- ADDITIONAL COMMENTS---- - ---- - ------- ------------------------ - - - -- ------------------------------- ------- - - ------ -- ------------------ ------------------------- ------------------- -------------------------------- ------ ---- --- -_ .......-.. -.. -------------- ------------------- -------------------- ------ -- -------------------- --------------------------------------------------------------------------- --------- - --- -- - ----- --- - -------------------------------------- ---- ----- --- -- - --------- ------- - - - ----- Final Inspection by:------ ate - Date. - 7 > EH 13 24 SAN JOAQUIN OCAL HEALTH DISTRICT F8�5 21677 REV. 7/76