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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ ------- ------ ------ - ------------------------- -.......................... (Complete in Triplicate) Permit No_. _l__::S G� Date Issued .. �_�� ...........................---- ..................... This Permit Expires 1 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 Ordinance No, 549 and existing Rules and Regulations: JOB ADDRESS/LOGATION_...: Q-- ../......., G�/- �..L.../ sDl/f7 !T � -------- ----- ------CENSUS TRACT............... Owner's Name.`�j X. ---- ..>._.4...�� .. -AV..L� . Phone. -- --.-- Address.... .... ...... cityo� d+j I� f. .......___Zip -=-------------------- Contractor's Name--F 1 ' ' �- 4e_Z ......................... �� Phone_.`.t"�- Q- - License Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----- ----------- .......................... Number of living units:....... .._.....Number of bedrooms............Garbage Grinder------------Lot Size--..-..--- _- ... ---__...:__....--........ . _ Water Supply: Public System and name-------------------------- -- --- ---- - --- -- ---------------------------------------_ ...__...-.._..---•- ---......Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ 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. 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 ( ] r' Size----------_------------------------------- ..Liquid Depth.__::..............:. ... ' Capacity.....................Type------------- ....Material---------- ------•. ..:No. Compartments------ -•---- ---...- Distance to nearest: Well------------ ------ -- --- ---- --- -----Foundation..---- ..... Prop. Line...................-------- LEACHING -.--. -LEACHING LINE [ ] No, of Lines.............................Length of each line,........._._.-----------------Total Length 'D' Box............Type Filter Material--------------------Depth Filter Material......................................--------.................... � Distant&to nearest: Well----------------------------Foundation........................... Property Line..................... SEEPAGE PIT [ ] Depth.. Diameter--------------------Number.._..._. ..-------------------- Rock Filled Yes ❑ No❑ Water Table Depth......................... . . . .........................Rock Size--..-..-- -----------------: ..--------- Distance to nearest: Well----------------------.............-.-_-.._Foundation..---..........-..-.......Prop, Line-----_----------- --------- REPAIR/ADDITION (Prev. Sanitation Permit --.--.-. --- _ ----------------- -----._.Date.--- ----------:- ---------------------------- ) Septic Tank (Specify Requirements)......- .. Disposal Field (Specify Requirements)_;--- ---• ..................................... --------------- -------- .................... - ........... .. - .. ------------------------- - --------------------- (Draw - ------------------(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 I 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------- Owner aY /1/1. ...Title (If other than owne OR EPART NT U E ONLY '✓ c� .._DATE APPLICATION ACCEPTED BY_......... . .. . 1 .. �' ..---------...... - ��- ..21 - DIVISION OF LAND NUMBER -------------- ------ -------------- ----- -----------------.-----------.....DATE.... ADDITIONALCOMMENTS ------ --------------- -------------- - --- - ----------------------- ----•----------------- -------------------- --...... . ---------------- -- -------------- -------------- ----------- ------- -------- ----- i -------------------------------------------------------------------------------- ------- -------- ---------- i Date... Final Inspectlan b - ----------------------------- - �-- - - �_.-• --. -- - -� - ...-.... ---.... ---- EH 13 24 SAN JOAQUIN L HEAL I ICT F&S 21677 REV. 7/76 3M