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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' t (Complete in Triplicate) Permit No: ---------- ----------------------------------------- - fi. ----- This Permit Expires 1 Year From Date Issued Date Issued 7 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 wit ount Ord' once No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ------------- t -- -•--- ----- ----- ---- ----------------------------CENSUS TRACT _S__5�'_- .: ------- Owner's Name !t"-J( ------ -- - ------------------------------- r__.Phone ------ - Address __:;- -41-- �� - '------------------------------•--. City -- , ,�=5 Contractor's Name ___ __66N.License # �4.0- Phone installation will serve. Residence ❑Apartment House❑ Commercial %Trailer Court ;❑ ! Motel ❑Other -------------------------------------------- _ Number of living units:------- Number of bedrooms ---0___._Garbage Grinder.--.-O---- Lot Size° ---- _-_ Water Supply: Public System and name ---------------------------------- ---------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'X Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 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,l PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] 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 -------------------------------------------- ; Distan'ce;ta nearest: Well ______________________ Foundation -------------------- Property Line ________________________ - SEEPAGE PIT [ ] Depth --- ------- ----- ----- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No [3 Water Table Depth ------------------------------------------------Rock Size ------ -------------------- Distance to nearest: Well ________________________________________Foundation .------- ....- Prop. Line ..................... ' REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------- ---------- Date _-__--_____-__-__-.-__--______----} Septic Tank [Specify Requirements) -- ---------------- --------------------------- ------------- ------ Dis osal Field (Specify Require encs} - -- ------ ------ ----- Q3: ' --- �--r----- -- --------------- - ----•-- ----- 3 - -, - - --------- ------------------------------ ------ (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 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 k as to become subject to Workman's Compensation laws of California." I Signed -------- Owner BY - --------- Title ----- - ;-------------------------------------------- iii ------------ ------------------------------ (If other tha owner} f FOR DEPARTMENT USE ONLY ff APPLICATION ACCEPTED BY .___ _ _ __ . _ DATE _f. .l - ----------------- BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- fADDITIONAL COMMENTS -- ----------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------•- ---- --------------------------------- ----------r--- ,aK Final inspection b _____Date _____.._____ ____ -------------------- r SAN JOAQUIN ,LOCAL HEALTH DISTRICT A E. H. 9 ]-'S8 Rev. 5M 4, . n