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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit ---------------- - ------------------------------------- -------- (Complete in Triplicate) 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. t This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:, ' Y --------CENSUS TRACT------------------------ JOB ADDRESS/LOCATION------ Phone----- -------------------------- ---- I, Owner's Name.__.__-_ Address. l- �r � ------------City.-, ---------- --------- -----Zip---------- ------------------ -- -- ------ - - r y- - Contractor's Name-- J 1 -----------`----- License ZZz_,'� e - - - - - __ #3 Phone Installation will' serve: Residence Apartment House flCom_ mercial ElTrailer Court ❑ Motel -- -----'-- ----------- 9 z ❑ Other-.-`---=------ -- ' 1 - Number of living units:-----_---------Number of bedrooms_---_..--__Garbage Grinder.___- Lat-Size_-" �- � - 1 �s � --__.,_.Private 0� y ------ ------- Water Supply: Publia depth of 3f feet; Sand Silt Cla • m Character of soil to p Sandy Hardpan ❑ ' Adobe ❑ Fill Material- P�If yeEl s, tYpeat Loam ---- oar (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) fi NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,( Size- v`� : - :-------------:--------------------------Liquid Depth----------- -------------- PACKAGE ------------PACKAGE TREATMENT t ] SEPTIC TANK [ ] . 4 . . Capacity- -- =Type = Motorial_. ", -^_--.-.-.-ND. Compartments-----------------------=------- t Distance to.nearest: Well - j`-Foundation.- ----- --- --=----Prop. Line = t [ Total Length -`------- ---------=----------- LEACHING LINE [ } Na. 'of Lines,..---.--;--.----------: Length of each line._....----"-!_'. .-------- . g ' i t Bax-----------Type Filter Material ---------Depth Filter Material ------------------------------------------- 'D' � .� . . t [. JET Distance.to nearest: Well------------------------- R dation- -------------}-------'----Property Lihe -------_111 ---------------------- Fours SEEPAGE PIT [ ] p - ,. Ye N ❑ Depth Diameter.:,: rNumber ' Rock ;`iliad s.❑ o Water Table Depth - ----=-- -:---- --;- --.Rock Size--------------- ---- ----------- i• ( - t Foundation - - .PrapY.Line-- ---------------- - 4 Distance to nearest: We11---------------------------- - k Date-------------------- --- ------------._y�} , ----------------- REPAIR/ADDITION (-Prev:Sanitation Permit#--.-------.----- ----- - . ------ ---------------------� -----= = = = - ` Septic Tank ]Specify Requirements)-------<.""--__-:-_-- - �;� a -------- - -:-------- ------------------------ Disposal Field (Specify Regpirements)------ r .1! .✓ - --=------=------------ = (Draw existing and required addition on reverse side] I hereby certify that.1 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: r "1 certify that in 'the performance of the work for which this permit is issued, l shall not employ any person in such manner gas to become subject to Workman's pensation laws of California." t - E Signed------- ----- -----=---------------- ------- -- -. Title-Own ea' x." B GAS i - (Ifother than;owner) 4 FOR DEPARTMENT USE ONLY - -------D ATE - APPLICATION ACCEPTED BY__::---_ = --------------- ---------- - DATE----------=---------- --------------- . DIVISION OF LAND NUMBER -"--------------------------- :_.------- ---------------- I ----:-- ------------ ---- -- ---ADDITIONAL COMMENTS----------------- ----------------- r -------------------------------------------------------- ------- - -------- ----------------------------------------------------- _ - - - ------- -- -� --'2- ----------------------=------- --------------------------------------- ----------- --------------------------- -------- -------- -------- - ----------- " --------- ------------ - - - - - Final Inspection b SAN JOAQLiIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M EH 13 24