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FOR OFFICE USE: FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No...................___ ------------------------ -------------------------------- Date Issued__(---_,,*'_7__7o4' --------- --- --= This Permit;Expires 1 Year From Date Issued aY � r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. rdin This application is made in compliance with County Oance No. 549 and existing Rules and Regulations: �. 4 �... �._._ _ T JOB ADDRESS/LOCATI N._4P/�----g -- . ----------- CENSUS TRACT-------- -:------ Owner's Nam ----- ------ . .�--- --------- - ---- -------- --- --- ------ - Phone ------ --------- -- Address- -.-:-------(a-J�--- ��' City -. Zi - Contractor's Name------ --- - --- ------- =---%G ?------------- =------License #---' 2-_�. hone Installation will serve: "`Residence [g/11Apa'rtment House r❑ Commercial ❑ 'Trailer-Court ❑ -Motel ❑ Other--------- ' - = .. . 'I• [ Number of living units------- -------Number of.be'drooms._. ¢ Garbage = _ =------- -------=--------- -------- Water Supply: Public System and•name---- --------- - Gar- a e Grinder size - '- --; private [X� ---- -.-} -- r Character of sail to a depth of 3 feet: Sand ❑ Silt❑ :Clay Peat ❑ Sand.y.Loarrl_Cl Clay Loam ❑ Hardpan ❑ Adobe 0 Fill Material__ ---------If yes, type------- _.`_ c:.__.---------- {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 ` - "f [ l Sze = Ar=---- - ---- -- =----------------- --------- Liquid ,Depth --- ---------=------ { Capacity---------------------Type----------=-- -1'=�'-Material- ' No. Compartments------- ------------- ° I r .t _ g a Foundation._ ''` Length --- --------' -------- Distance .to nearest: Well____________________ Prop! Line ------------- C LEACHING LINE ['] No, of Lines....__-------- -_-- -.Len th of each lin&------- ------- Total len g 3 'D' Box--.-._______Type Filter Material--------------------Depth Filter Material-- ____----___--__-.----__ i Distance to nearest: Well- ---------------------------Foundation------------------------___.Property Line.-____-_.___._______________.___ SEEPAGE PIT [ ] 'Depth-----------.....Diameter--------------------Number---------- ---------------------` Rock Filled Yes ❑ No❑ Water Table Depth---------- -----------------------------------------------Rock Sizer-------------------------------------------------- Distance ------------------ ---------------------------- Distance to nearest; Well__________________________-.----------_--.Foundation----"___,.--------- Prop, Line------------- ------ REPAIR/ADDITION (Prev. Sanitation Permit#------------- --__,_ -. *,-------.Date-- ----------- .,. Septic Tank (Specify Requirements)__---- ---------=.......-].Y,_--------- n------------- -------- ----- Di p -Disp s Field ecify Re uirements _____ _ ---------- '_ --------- - --------------`W-4-44 ---------- - --- �-_ ------- ---- ISI (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, 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 become subject to Workman's Com s tion laws of California." Signed------- - 'Owner -� By--------- ----= - ---(�-- .- - ----- -- Title--- --- --- - �w -------------- (If'other than owner) FOR DEPARTMENT USE ONLY Ll APPLICATION ACCEPTED BY-------- ---------------------- ------------------------ DATE.----- ---------- --------------------: DIVISION OF LAND NUMBER --------------- -------- --------------- ----------------DATE.-------- --- ADDITIONAL COMMENTS- ------------------------ --------------------------------------- --------- -------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------- ------------------------------------- Final Inspection by:-..__ o- - Date . eFr 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M � r