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s# FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ ' Permit No. -- ----- ------------ ---------------------- ----- =---- G (Complete in Triplicate) ------------------- ------------------ ----- a 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 i described. This application is made in compliance with County Ordinance No. 549 and existing� Rules and Regulations: JOB ADDRESS/LOCAT.ON , l��i-- � - '� --CENSUS TRACT ------------------________ Owner's Name .__ ''` S -Cit Phone ------------------------------------- ------------------ city ------------------•- - ---------------------------------- Address ----------- L Y Contractor's Name . _ -_ T�y-r� ------------------'----- License #�� ,3 Phone -. Installation will serve: ��' Residence KAAp^artment House❑ Commercial []Trailer Court ,❑ Motel ❑ Other -------------------------------------------- g :-I- ---- Number of bedrooms __________Garbage Grinder __-_._.--_- Lot Size __ t - --------------- Number of living units.._-'._I Water Supply. Public System and name ---------------- =---------------------------------------------------- Private [ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Peat ❑ Sandy Loam -❑ Clay Loam ❑ e. 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 see ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ Sized_- F *�- Liquid .Depth A/---------------------- - -- -- -- ---------------------- Capacity j OQ Type - Material__��No. Compartments -4 ---------- ip s S Distance to nearest- Well ----------tet'--------•------------Foundation -------j-4'--------- Prop, Line ---------------------- ' LEACHING LINE [ No. of Lines ------/---------------- Length of each line------ -V_EQ-------- ._____ Total Length x� 'D' BoType Filter Material ---S __ _ -_____Depth Filter Material ____--_- -------------• Distance to nearest: Well ------/ ------- Foundation --------ZD........... Property Line. -S_--•-- ----------- SEEPAGE PIT Depth _--- s t----- Diameter --------- Number -- ------ _ I-__ `-- ----- Rock Filled Yes No I❑ [� �-----.- Water Table Depth Rock Size �z-_x- --1�-- ------ r ----------------- Distance to nearest: Well -----------i Q!q-------------------Foundation -------------------- Prop. Line`s------------------- REPAIR/ADDITION ------._ . - REPAIR/ADDITION(Prev.'Sanitation Permit# -------- ----------------------------------- Date --------------------------------="I""" Septic Tank (Specify Requirements) -------------------- ---------------------------------------------------------------------------- Disposal Field (Specify --------------------------- Requirements) ------------- ------------------------------------ ----------- - d (Draw existing and required a ------------------------------------------------------------- - -------------------------- -------------------------------- �i 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 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 as to bee me subject to Workman's Compensation laws of California." Signed �ner) -------- Owner --------- Title _�� - �------------------------------------ (If other than o FOR .DEPARTMENT USE ONLY -�---�-- APPLICATION ACCEPTED BY ---- -- ---- ----- -- ----------------------------------------- --- ------- DATE'-- - l° ----------- ----PERMIT ISSUED ----------------------- -DATE-------------------------------------------- ADDITIONAL COMMENTS ----------------------------------- - ----------------- --------------------------- ------------------------------------------------------------------------------ ------------------------------------ - - - ---------------------------------------------------------- Final Inspection by: __.,._ ------ ---------------------Date __ - - � ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M