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A FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------- - Permit No. ----- ---- (Complete in Triplicate) ----------------------------- ---------------- -------- This Permit Expires 1 Year From Date Issued flats 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.i.s.mcide in,compliance,.with County-Ord inance-No..549 and existing-Rules and Regulations- 451 JOB�ADDRESS/LOC _ a J CQ�' -----CENSUS TRACT -------------- ----------- Owner's Name f -------------------------- ----------------=-------------------Phone ----------- -------------- :-------- ` . City ---- J --- ---------------------------------------------- - osAddress T Contractors Name-------- __ 1 License # Phone ------------------- Installation ' --- installation will serve," Residence Apartment House�❑ Commercial.:❑Trailer Court 0 Motel -_------------------- ❑Other,== = ` .> , ----- - - Number of living unit's-------f---. Number of bedrooms J--______Garbage Grinder --------____ Lot Size __________________ -_____ _:______-___ ^� _ V t Water Supply: Public System and name ----------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sdnd'❑ ilt p Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ { r � � Hardpan Adobe.-E] Fill Material------------- If yes,type ---------------_._-__._____ , 4. (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,) sJ PACKAGE TREATMENT [ SEPTIC TANK f I Size------------------------------------------------ Liquid Depth ---------!------•--------- Capacity --- ----Capacity -------------------- Type ---------:-- Material---------------------- No. Compartments ------------ �J - . Distance to nearest: Well ______________ __—_____--_____ -.-Foundation ------------------- -- Prop. Line _________._____._.___ Is < LEACHING LINE No.sof Lines ---. ------------- Length of each line____________________________ Total Length ._________.________..._...__ 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------------------._______._..____.._._.__ 4 Distance to nearest: Well ________________________ Foundation ------------------------ Property Line, --------- ------- SEEPAGE PIT [ ] Depth -------------- Diameter ---------------. Number ___________________________ Rock Filled Yes 'Q No (] Water Table. Depth --------------------------------------------.---Rock Size --------------------- V! Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------..__---- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ___-________._____--______________) Septic Tank (Specify Requirements) --------' -- -------------------------------------------------------------------------------------------- ------ Disposal Field (Specify Requirements) -------' ---------------------------------------------------------------------------------- ------------------------ --------------- -----——-——-----j---- -------�L-- ----—-------------------—--=-------------------—---------------- --—-—----——------------- 1 -.__e 4/ (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: w a "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 r �• Title l E BY -- - ----- ---------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ =----------------► -- ----------------------------------------------- DATE "�. BUILDINGPERMIT ISSUED ----------------------------------------------------- ------------------------------------------•--- -----DATE -- ---------------------------------------- ADDITIONALCOMMENTS --------------------------------------- ---- -------------------- ----- ---------------------------------------- ------------- ---------------- ------------ --- -------------` _ __ _ -- -------------------------------------- , `-------- ------------------------ ---- -------------------- --------- --------------------------------------- -------- ------- - ------ _ -. --- ----------- ----- Final Inspection by. - ----------------------------------- ' SAN JOAQUIN LOCAL' HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M