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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT G f -------------------------------------------------------- { Permit Airy (Complete in Triplicate) ---- ----- -------------------------------__----_----- This Permit Expires 1 Year From Date 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 incompliance with County Ordinance No. 549 and existing Rules and Regulations: S ` -p—L�'-=`_ ��--------- -- CENSUS TRACT ---Y ------------- JOB ADDRESS/LOFr�q N -------a___-_ ,_. 6 Owner's Name _ V l ------------------------------------------------------------ Phone Address City -- __ - - --------License #�T� _ Phone Contractor's Name .----- Installation will serve: Residence E?rApartment House-E] Commercial:❑Trailer Court ❑ Motel ❑Other -- ----------------------------------------- Number -------------------------------- -Number of living units:_._---- __ Number of bedrooms -Garbage Grinder ------------ Lot Size ----- ------------------ Water Supply: Public System and name ---------------------------------------- - f'------------.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 ___________________--__-___ (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,] U PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size--------------------------------------------- Liquid DT. epth ---------------------.----- Capacity _ Type -------------------- Material---------------------- No. Compartments - V i( Distance to nearest: Well ----------------------------•-------Foundation -------- ------ Prop. Line ------------------_-•- I LEACHING LINE [ ] No. of Lines ------------------------ Length of each line__:.._y_'_-s ,_____.______`Total Length _--------------.__________-- r 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------j--------------------- ----------- Distance to nearest: Well ---------------`_-_-__ Foundation- --__-.----_-_-.-..-_-____ Property Line. -.---_--_-___-___--:•-__ SEEPAGE PIT ] Depth -------------------- Diameter ---------------- Number ------ ---------------- Rock Filled Yes ❑ No .0 Water Table Depth ------------- ----- - --=------------------------Rock Size /---_--------------------- " Distance to nearest: Well ----------------------------------------Foundatio 1___---_._______.__ Prop. Line -------------- ------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- --------------------- Date _____----------_--_----._-________} Septic Tank (Specify Requirements) - t _-V------. ------------------------ Disposal Field (Specify Requi eme ) _ , � � - 1 r - --- - ------- - 4 _ f I herebycertify that I have prepared this applicationistganand required h;_ ----- ------ -------- - - dition on reverse side] fy p pa work will be done in accordance with San Joaquin i 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 prmit is issued, I shall not employ any person in such manner as to become suble kman's Compensation laws of California." Signed -------- ---- ------------------- - ------- -- ---- --- -------------------- -- Owner a BY ---------- Title - -—----------------------------------- her than owner) --- —FOR DEPARTMENT-USE-ONLY- - -- - APPLICATION ACCEPTED BY - ---------------------------------------------------------- DATE .L_ ------------- BUILDINGPERMIT ISSUED ------------------------------------------ -------t-- -----------DATE ---- -------------------------------------- ADDITIONAL COMMENTS ----------------------------- •= ----------------------------------------------- --------------------------- - ---- - --------------- ---- - ----------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------- ---- ------'=-_-- _ �' Final Inspection by: 1 }t A -------------------------- -----------------------------------------------------------Date/_- /. 'yy ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M.