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POR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......_._.. . ..................... Permit No. ...' Ja.7. ` (Complete in Triplicate) V ........................................................ This Permit Expires I 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. JOB ADDRESS/LOCATION . .�4. .....- .�J--._... ..... �......................... .....CENSUS TRACT .......................... Owner's Name ......t .....�. �h.. u ,,�...._.. •....................... ------- ---Phone •?-Q.� ...... Address . -- � t � �_'.. City _ + . .................. _ _ �. Contractor's Name -4-------------------License #a . ..... .- ... - Phoney Installation will serve: Residence Apartment House,❑ Commercial []Trailer Court,. ❑ Motel ❑ Other 1 -3 Number of living units ' Nvmber „of bedrooms ..4r.;___...Garbage_Gririder' -.. Lot Size i._. _.X.I. 0........... .. N., -_.. Water Supply; Public Systeem and name ..... ........... .. ... � '.i. •.• ........................Private ❑ Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay ❑ Peat❑ Sandy Loam P( Clay Loam Hardpan p 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 [ ] SEPTIC TANK t ........ Liquid Depth ........... -------------- Capacity Type .......... ......... Material _-.... .... No. Compartments ______..__.__.._......� € Distancet nearest: � __ o a est: Well -..--------------------Foundar�on ..... .._..... . . Prop. Line .._..... ........... LEACHING LINE [ ] No. of Lines Length_of_each_line. Total Length ---------------------------- t � , I � f i 'D' Box ._... Type Filter Material -------Depth Filter Material ..- .......................................N Distance to nearest: Well ..._. ------. Foundation .. ............. .... Property Line _.._,__._.. ............ SEEPAGE PIT [ } � Depth •. Diameter Number ... ...... ........ ... .Rock Filled Yes ❑ No ❑ Wate.r-Table..Depth,.... -------------------------------------------Rock Size ---------- -------------------- I I 4 Distance to nearest: Well -•................----------............Foundation .... _• .... ..,. .. Prop.#line ---------__---.---_•-. REPAIR/ADDITION(Pr%v. Sanitation Permit# ... .... ............ •-.-----.....-------- Date --- .,._.---------------- Septic .-_.--- _-.-..-Septic Tank (Specify Requirements),, .. . ..- _------. Disposal Field (Specify Requirements) ......Q-d(._--- !4`,,; -5 ---- f! ..- ........... ............. .. ..... .... . ... --....:...1... .... -•--------- - ...... ... ... ----- ............... . .. ......-. . 1 _ - .. <<�;: .---- �' -.....-- - - .------------------ (Drdw existin g_and, rea uired addition.on reverse side) 1 hereby certify that I have preparedithis application and'fhat** he work will,1;e done in accordance with San Joaquin County Ordinances, State Laws, an'AIRulels and Regulations of'fhe'San Joaquin Local Health Distcici. 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." '! T Signed . .. ........ ... .. ...... . ..---- -- Owner BY �..... I ..... ... Title (If o e than owner) A V FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . . ........I... --------- ........ DATE ..._.... BUILDING PERMIT ISSUED ....... . ..... ... _ ..... ---------------------- .... ......... .. . .. .......DATE . ........................ ADDITIONALCOMMENTS ------- ----------- ---- ---------------.._...---- •---------- -.,. -------.... .. ........... ......................... ----------._..._..-•-.----------- ...................... .................---.....................................................--....... .......------ . -----.......... -- ----._._ ..... ---- � -- Date ..... .:....... Final � Final Inspection b ....... SAN JOAQUIN LOCAL HEALTH DISTRICT 1s`� � Y L3 24 7l`?Z K , E. H. 1--68 Rev. 5M ,