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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. 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 No. 549 and existing Rules and Regulations: qq j� JOB ADDRESS/LOCATION . �--1,------ ------ -- -CENSUS TRACT ------ ----- ------------- Owner's Name ------ rt,___ Phonet/� 4� -- ------------ Address -----.._. - --- ------------ - - -------------s i - City --- Contractor's Name -------- ----------- ----------License #. _ - - - Phones _. Installation will serve: Residence XApartment House❑ Commercial []Trailer Court o Motel ❑Other --------------------- -------- ------------- Number of living units:---__- .___. Number of bedr oms ____a------Garbage Grinder��--_ Lot Size --- _/A. __1�_'__----___----- Water Supply: Public System and name ------ --------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'[< Fill Material ----__- ____ If yes, type ----------------------------- W (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) W NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] X—,L't�S T�ize_G---------------------------------------- -- Liquid Depth ----.----------------.----. Capacity -------------------- Type- ------------------- Material---------------------- No. Compartments ------.---- / istance•to nearest: Well? .�"- --------Foundation ---------------------- Prop. Line -----------------•-••- LEACHING LINE [ ] No. of Lines ____-____-________V____:�Length of,,each line--------------------- ------ Total Length _-___-____-_______________- 'D' Box ____`._____ Type Filter Material _-_-__-_-________Depth Filter Material ___________________________--.-_____.____._ S �- Distance to nearest: Well ------------------------ Foundation ._____--_____-_________ Property Line -------.__________-_-___ SEEPAGE PIT Depth _ `/14' Diameter ri Number ----------.J_.__.._____ Rock Filled Yes � No Water Table Depth -----� --r--------- - ----- ------------------------ Distance ------------ -- '� Rock Size ____ Distance to nearest: Well _ -__ 'e________Foundation ----`Q_-------- Prop. Line ------ -------------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------- --'--------------- Date ----------------------------------) Septic Tank (Specify Requirements) -------- -------------- ----------------------------------- --------- - -------------------------------------------------------- -- - Disposal Field (Specify Requirements) - f ----- ----- --------G'+``---- -------------- � � ------------- -------- 3--------- ----- ------a---------------------------------------------------I------------------------ --------------------------------------- -- - --------------------------------------- {Draw'existing and required ad ` dition 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: "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 become subject to Workman's Compensation laws of California." Signed ----- --------- ----------- Owner ---------------------------------------�---- By - ---- Title - ---------- --------------- (If other than owner) FOR DEPARTMENT XSE ONLY _ # —2;7/ � APPLICATION ACCEPTED BY __-- -- 5----._ _.,_---- DATE ----------- - - - --SIL------------- BUILDING PERMIT ISSUED -- -- - -------------------------- ---- --------=--------------DATE -------------•----------------------------- - ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------- --------------------------- - - Final Inspection'by: ----- --- -�1--------------------- --- -------------------------------------------- --- = SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M