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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- ------------------------------------- Permit No. f Z z (Complete,i Trip icate) { -- --------------------------------------------- I ________________ This Permit Expires 1 Year From Date Issued Date issued 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 N . 549 and existing Rules and Regulations: D JOB ADDRESS/LO TION . - � ` `` --- ....... -------------------CENSUS TRACT -------------------------- Owner's Name ------- -------- ---- ---•----•---------------------------- -------------------Phone -------------------- ---- - Address -_- City ---------------------------------------------------------------------•------ y Contractor's Name - ------ --------------------------------License #17T-4--3------ Phone ------- -------------•-------- Installation will serve: Residence ❑Apartment House�❑ Commercial ❑Trailer Court I❑ Motel ❑Other -------------------------------------------- Number of living units_____________ Number of bedrooms -------------Garbage Grinder ------------ lot Size __- ___-O-�� Water Supply: Public System and name ----------------------------------- ---------------------------------------- ---- ------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat ❑ Sandy Loam Clay Loam :❑ t i 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,) PACKAGE TREATMENT [ J SEPTIC TANK'[ ] Size________________________________________________ Liquid Depth __--____________-__ ------ 1 Capacity --------- Type _t---------- Material------------------ -- 'No. Compartments --- ------__-•-- Distance to nearest: Weil -------_lr_p-----------------------Foundation' _. `_____________ Prop. Line _. . .............. LEACHING LINE No, of Lines ----__ __ Length Total Length _____ _ . L l �- -- ----- 9th of each line.------- �-f--- ------ �-- - �•---•-- •-•- 'D' Box ------------ Type Filter Material _______-_-________Depth Filter Material --------------------------___________________ ------ Foundation ---- _-____ ------ Property Line. --- f--------------- SEEPAGE _. ._ ._ ._ I Distance to nearest: Well __,�� _ � �__ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ____________________________ Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------- ----------_--.Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIRJADDITION(Prev. Sanitation Permit# ____________________________________________ Date ___-______________--__-._----_-__-) SepticTank (Specify Requirements) -------------------------------------------------------------------- --------•---------------------------------- --------------------------- Disposal Field (Specify Requirements) ------------------------- -•--•--------------------------------------------------------------------------------------•---- ---------- ------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------•------------------------- (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 ' 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: "1 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 -------------- --- - ------- -- (if oth r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.__ -/.� �--_---_--- L , I -��_ -------------------------------------- DATE 2-- l----- BUILDING PERMIT ISSUED -------- ------------------------- --- -------- -------------- DATE -------------•----------------------------- i ADDITIONAL COMMENTS _______________________________ --------------•------------------------------------------- ----------------------- ------------------------------------------------------------------------------------------------------------- -------------------------------------- '---=---------------------------------------------------------------------------------------------------------------------------------------------------- -----------------=------ -------------------------- Final Inspection by: -- ' r _Y ------------------------- -------------------- --------------------------Date zfT -. ---------------- f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b6 Rev. 5M.