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FOR OFFICE USE:, APPLICATION FOR SANITATION PERMIT Y-,--------------------- (Complete in Triplicate) Permit No. ---- --------------------------------------------- This Permit Expires 1 Year From bate Issued Date Issued --- _ -- ----------- - ----------------- -- Application is hereby made to t Scn Joaquin Local Health District for a permit to construct and install the work herein described. This application is rude in complian w' CounP Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOC ONE---///------ :---- --- - ---- ---------------------------- ----------------------CENSUS TRACT -------------- ----------- Owner's Name ---- ------------- ---- ------- ----- one ��-7_-�-----�--`�--`-5- Address - � d --- - -��-�J�--- ----- •--- �l_ ----. CitY � Q^"o Contractor's Name ---------------------•------- ------------------------------------- ----------.License # ------------------------- Phone ---------------------------- f' Installation will serve: Residence ❑ Apartment House❑ Commercial -]Trailer Court ;0 O Motel Other �� _________________ Number of living units- O- -- Number of bedrooms __________ Garbage Grinder ------------ Lot Size -------------------------------------------- 71 Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat' Sandy Loam ❑ Clay Loam 0 � 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: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAN Size--_-_ . ire-_ ---.--.- Liquid Depth -------------------------- Capacity-� Type -------------------- Material------- -------- No. Compartments ------------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------7-- -LINE [ ] No. of Lines x_S ength of each One ________________________-_ Total Length -.___._-_-_- D' Box . _ . ----- Type Filter Material p th Filte�Maferial 1-y------ ------------/...----- Distance to nearest: Well ,lfi41___-�_---- Foundation ..1d ---------- Property Line �_...__._____ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number _-.------------------------- Rock Filled Yes ❑ No Water Table Depth ----------------------------------- ------------Rock Size --------------------------------- Distance __________________ __ _Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ....------------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------.----------------I Septic Tank {Specify Requirements) --------------------- -- --------------------- ----- -----------------------------•---------------------------- Disposal Field (Specify Requirements) ,----------- ------------------------------------------------------------------------ --------"-------------------------- ------------------------- ------------ ---- ----------- --------------e---------------------------- --------------------------------- v -n required ----------------------------------------------------------- (Draw existing and q d 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: "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 became subject to Workman's Compensation laws of California." _ Signed --- - ---- ----- ----- ------ --- -- ------ ---------------------------------- Owner r By ----- --- ------- - - ----- ---- - -�' Title ----------- (If other t n owner) r - F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----�