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FOR OFFICE USE7 APPLICATION FOR SANITATION PERMIT "... ... . ................... ..... Permit No. ..................... • � ...... "' (Complete in Triplicate) ......... .................................... Date Issued ............... This Permit Expires 1 Year From Date issue 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: B ADDRESS/LOCATION ............................. ..........................CENSUS TRACT ......_......_....._...... ............................ Phone Owner's Name . .......................................... _.._........ Ci ........... Address Phone ....... .................:..._......._..._ City Contractor's Name .--...__"-.-._...- ---- License --••-....... ... Instollation will serve: Residence Cj Apartment House C] Commercial ❑Trailer Court ❑ MotelOther ------------------------•-••------••-•----•- Number of living units:.. Number of bedrooms ............Garbage Grinder ------------ Lot Size ..._..._..----..-- ....... ..........-- : Private.C3Wafter Supply: Public System and name,-------- ............ .................. •------____---............................................ Character of soil to a depth of 3 feet.' Sand n Silt❑ Clay (3Peat[ISandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe ❑ Fill Material ......... if yes,type ""------•._------- -------- (Plot plan,.showing size of lot, location aftsystem in relation to wells, buildings, etc. must be placed qn reverse side.) NEW INSTALLATION: (No septic tank or. seepage pit permitted if public sewer is available within 200 feet,) SEPTIC TANK Size......................................... Liquid Depth .......................... PACKAGE TREATMENT I } a Capacity __..--•--•._..._.._. Type Material.---------••...._..... No. Compartments .................. Foundation "-._ Prop. Line :............:........ Distance to nearest: Well •••••••-"--"" Len .... Total LEACHING LINE l No. of Lanes _..,--------•...........• gth of each line..----------••-------... Length ............................ 'D' Box Type Filter Materia! ....................Depth Filter Material ----------_------- ........................ Distance to nearest: Well ---- ................... Foundation Property Line -"---------------------- Diameter Number .............--•-•••. ---- Rock Filled Yes ❑ . No t❑ SEEPAGE PIT ( j Depth ..---... Water Table Depth ...................................Rock Size --------.................•------ Distance to nearest: Wel! ............. I........................Foundation _----------------- Prop. Line ...---- ............ REPAIR/ADDITION(Prev. Sanitation Permit# ------•-•••............................_..._. Date ................................... Septic Tank (Specify Requirements) ...................................................................................---------------------- ................-...... ...... Disposal Field (Specify Requirements) ----------:---------- ........••-"-•"••••__...........I...... -----•-- ---- - .:.. (Draw existi..ng and required addition on reverse side) I hereby terrify that l have prepared this application and that the work will 6e 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 manna as to become subject to Workman's Compensation laws of California." Signed ..........--•- Owner -.----_--------•---...---- BY .....................................:........ ---....... Title _..----......-----.....----•-•--•-•----.. ..............1. (If other than ownr) FOR DEPARTMENT USE ONLY APPLICATION. ACCEPTED BY ...............................:-__......_.___._............................... ....... DATE ....---................................. . BUILDING PERMIT ISSUED ............. DATE _......._.._..........---............-•---• ADDITIONAL COMMENTS ................ •----- ---------..------- -•..............................................:..... - ..................................•......_._...._..._...... :. ..Date • Fina! Inspection by: .......................... ..... ....................--.......I....................... -._.-.- .—_.SAN JO.AQUIN LOCAL HEALTH DISTRICT •�� - 7/723 M 13 241_•mq i?.,, _w _