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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) -------- This Permit Expires 1 Year From bate Issued Date Issued f - - _- 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/LOCATION ._f 7. :-- -------------- _ r/. ------------CENSUS TRACT -- --- - ------.- Owner's Name ------ s ------ - ----------- --- ---Phone ------------------------- Address = City - --,c ---- Contractor's Name -�� --.License # J1137-y"' _11. 3 7�Phone ---------------------- Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court Motel ❑Other �T i Number of living units:------,__-- Number of bedrooms ___/------- Grinder -_____-_--- Lot Size ___-_-----------------------_-_ Water Supply: Public System and name ------------- - - -'-'-`- =--------- ----------------•------ -------------------- -------------.Private ❑ Character of soil to a depth of 3 feet: Sand'[Ksllt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :0 Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ------------l----_- (Plot plan, showing siieof 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,) I PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_______________________ _ --- -------------------------------_-- liquid Depth ---- Capacity -------------------- Type --------------------- Material-- ------------------- No. Compartments Distance to nearest: Well ----------------- --------- ------Foundation ---------------------- Pri p. Line ------------ -------- LEACHING LINE [ ] No. of Lines --_---{______-.-_____-- Length of each line`_________________ _ ------ Total Length ----------------------- 'D' Box ------------ Type Filter Materiali ---- ----------------Depth Filter Material ------------E ------ Distance to nearest: Well ------------------------ Foundation Property Line --------------- __.:-. SEEPAGE PIT [ Depth ---------------- --- Diameter ---------------- Number ---------.------------------;Rock Filled Yes :ElNo 0 , Water Table Depth ------------------------------------------------ Rock Size- -------------------•------_- � Distance to nearest: Well _ -----_____-------------------._«=----FoundationM1__`W ___-.---__ Prop. Line ="---_._ ..__ ' j ) REPAIR/ADDITION(Prev. Sanitation Permit_# _______.._ --------------------------------- -----� � 4 Septic Tank (Specify Requirements) --- any ------------------' ------ Disposal Field (Specify Requirements) ---------------------------- -- ----------------------------------------------------- ---------- I -------------------------------------�- w - -'-- 1 --- - - -- --- ----- --------------------- -- ----- - - . (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 accordan[e with San Joaquin County Ordinances, State laws, and Rules and Regulations of the Sean Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: j "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 subje Workman's Compensation laws of California." ? Signed ---------- Z - ---- -------- i--Bvpnzr i BY ---- w - Title [If other than owner) -- -- -- - ------------------------------------ FOR -----------------FOR .DEPARTMENT-'USE ONLY APPLICATION ACCEPTED BY --- ------- ----------- DATEBUILDING PERMIT ISSUED ----------- --- ------------ - DATE ADDITIONAL COMMENTS --- ------- ---------------------- ---- --------------------------------------------------------------------- ------------------------------------ ----------------------------------------------------------------------------------------------- ---------------------------------- Final Inspection by: ------------ -----------------------------------------------------Date _ �. _� �------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1 '68 Rev. SM.