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FOR OFFICE USE: f - "�� APPLICATION FOR SANITATION PERMIT 7 S _�3 ............_. _..-----•------------------------------ -- . (Complete In Triplicate) Permit No. . ................... .. . .. -� x This Permit Expires t Year From Date Issued Date Issued .� ...r........... 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 compliant . ith County Ordinance No. 549 and existing Rules and Regulations:- . �J JOB ADDRESS/LOCATION � ,..-...'I..... ....... .. �_.. ._..._.............................CENSUS TRACT .......................... Owner's Name ..t ------ ----- .............. ..... ............Phone .............................._..... Address o'20___ _7 ..... ....C -. ............................................ ... . icy Contractor's Name ' ..... Q:. �..... ....... .License # .��.�� Phone Installation will serve: Residence partment House❑ Commercial❑Trailer Court C Motel ❑Other Number of living units;...... Number of bedrooms -....Garbage Grinder ............ Lot Size .... ........ Water Supply: Public System and name ........................................................ ........................ ...............Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam lay Loam ❑ r ' Hardpan El Adobe 0 Fill Material If yes,type (Plot plan, showing size of lot, location of system in relation to--wefts;build1h- s, etc. must be placed on reverse side.) O NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( } SEPTIC TANK } ....._- Liquid Depth - � Size.....................�..----------• - ....................... Capp,city --- }..... Type -------------------- Material..---------------------- No. Compartments ..................... Distance to"'nearest: Well .:.................:................Foundation ...................... Prop. Line ...... .......... vF ' • LEACHING LINE [ ] No. of Lines----------------------- Length of each line.........._._...._........__ Total length ............................ 'D' Box ------------- Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........ s Foundation ........................ Property Line ........................ SEEPAGE PIT ( ] Depth -----------------`_. Diameter _._.._... ...... Number ......................... Rock Filled Yes ❑ No �] Water Table Depth ............... ................................Rock Size .------..... ............. Distance tonearest: Well ...................... _ ------------------Foundation .---................. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ...........---------- ........ Date .............. Septic Tank (Specify Requirements) ...:..................... =j---------i........................... ..................._...........-. ----------------- --------- ' -�� Disposal Field (Specify Requirements r - -- .... L-.._C' ^----•-....•,•__......... .� --------. _____ ..... - --------------------------- -....................................................... (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 r 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, 1 shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed -- ------------------- -------------- - -_ ---- -----_------•-•----- Owner By ----------------------------- --- ------------ �...-.._ ---------- Title (`e.- - (if other t an owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- DATE ,.. .. - BUILDINGPERMIT ISSUED --------------•------------------•-----------------------•----------__---------------------------- . .DATE .... ------ --••--- ...... --... ' ADDITIONAL COMMENTS ......................................... ------ -- -------------------- ---- _... Final Inspection by: . -- - - -. .r . .... .................Date .- ` ................... .... -••.................. EH 1,3 24 1-68 Rev. 5H SAN JOAQUIN LOCA! HEALTH DISTRICT 8/7h 3M