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FAR OFFICE USE: ; APPLICATION FOR SANITATION PERMIT �.. � Permit No- ----------- -----• --- (Complete in Triplicate) 2 v -------- ------ - Date issued --__- -.---- This Permit Expires I 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/LOCAT J9N .__ ° ------------ - ------ ------CENSUS TRACT -------------------------- r Owner's Name ---- -------------------------------------------- ------Phone ------------------------------------ Address - ---------- - -----•--------•----Address �-' aG-- City .--- -- ----- -- .Lice nse # A -p-700'r--- Phone ------------------------ Contractor's Name _ --- Installation i will serve: Residence [Apartment House❑ Commercial:❑Trailer Court ❑ Motel ❑ Other -------------------------------------------- w - - ---- Nu -� = -- - Number ofLLliving 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 -____-__.__------------.--- y (Plot plan, showing size of lot, location of system in relation rto wells, buildings, etc. must be placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) `A PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size--------------------------------------- - Liquid Depth -------------------------- �,k Capacity ------------------ ----- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ ---------._.... ` Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----.----------------- f ______ Total LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_--------------- -- Length --------------- ------------ 'D' Box .----------- Type Filter Material --------------------Depth Filter Material --------------------•---------•• -- Foundation --------------------- Property Distance to nearest: WeII _________________ _ Pro er me ________.----„----__--- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes C3 No i❑ Water Table Depth ------------- --------------------------------- Rock Size Distance to nearest: Well -------------------------------- -------Foundation -------------------- Prop. Line ------------------- iii REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------=------- ate ------------------ ----------------- t Septic Tank (Specify Requirements) -------------- ---------------------------------------------------------------• -------------V, Field (Specify Requirements) __-_ ---•----•---------------------- ----------------- G� ------------- ------------ ---------- 3 3 'y ------------------------------------------------------------- -------------------- ------------ (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 licen- sed agents signature certifiesthe 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 Compensation laws of California." Signed --------------------- ----- Owner t By --------------- -------------- ------------ Title - - -- ------ - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --,� -�4- - DATE _ '"- ^: - -/�- ---------- - - --------------------------------------------- - 4 BUILDING PERMIT ISSUED --------------- -----DATE -------------•-------- ------------------- -------------------------------------------------------------- ADDITIONAL COMMENTS ------------- -------------------------------------------- i --------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- E -------------------------------------------------------------- __________________________ _ - ---------- ---------------------------------- ._._____ Final Inspection by: __ - �--------------------------------------------------------------------------- .Date '' ` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M.