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s ' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .............................................. �.7..."/ - (Complete in Triplicate) Permit No. ..... This Permit Expires 1 Year From Date Issued ..:. Date Issued ......... ....... f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein t } described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOC ION ^ L '� ....................... ... ��L�!cx�'f� ...........CENSU5 TRACT Owner's Name ------•-••---•-- .........Phone............................-........ . ..... _...--- Address .......... � /..''J..... - •............., CitY ' .......................... .......... - -----�- .............License #D�_? .. ......_ Phone . .. ._..... Contractor's Na e _ _ .;�..._........ �_��:_• � I Installation will serve: Residence artment House 0 Commercial❑Trailer Court ❑ r Motel ❑Other `---------------------•--•----•----------- ► Number of living units:............ Number of bedrooms ............Garbage Grinder ............. Lot Size -----------..__.._.---------;............... Water Supply: Public System and name ........ .........--------•...............................-.............................. ..............Private'❑ Character of soil to a depth of 3�feet.- Sand❑ Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loom ❑ i fHardpan ❑ Adobe ❑ Fill Material ............ If yes.type ____________________________ (Plot plan, showing size -af lot, location of. system in relation yto wells, buildings, etc. must be placed on reverse side.) k R� NEW INSTALLATION: (No septic tonk`or seepage pit permitted if Public sewer is available within 200 feet,) PACKAGE � - TREATMENT SEPTIC TAN' ae....... ._ - . �..�............ Liquid Depth ._ :_..___-_ Capacity<./a��..... Type Materia.(- _ � �-?� .-•--•- No. Compartments ��.•... Distance.°.ta nearest: Well .____. 0.�...................Foundation ......... Prop. Line ._. f.__.:...._.� LEACHING LINEy No. lof Lines -_._L............... Length of each line_t tx�._r�� :`.._.__.. Total Length l� .f. '....._..... 00 'D' Boz fi�e'Filter Ma'teri`al � - Ai �l�S----• YP -------------Depth" Filter Matenal_- •.f%�:�.:::':........__......._....._.. Distance to nearest: Well ---s; - Foundation _...� _! Property line �`� SEEPAGE PIT Depth ..c ..�- Diame rfid_...... Number ...... ............. Rock Filled Yes No ❑ Water,Toble Depth _____. . .-..........-•_--•---•-•........Rock Size .l :�J!- --�--- ------ � r .. r.�D'stance to nearest: Well __....../�.........................Foundation .l-d_.__�---_-- Prop. Line -/-- ............... REPAIR/ADDITION(Prev. Sanitation Permit# Date fl Septic Tank (Specify`Requirements) 0 DisposalField (Specify Requirements) --- .............................--..............--•---•---..._..-------_..+_-_.--------------............................_..-•-.... i ...........................•--------...---------_._-----------................... •-•------ -•----••-•-----------------------------------•------------- --........----...---- --•---- ------------------------------------••- ................................................ J............................ .......................... ....................... -•-•---•---•--- (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, I shall not employ any person in such manner ' as to become subject to Workman's Compensation laws of California." Signed ............ =----- ------ - -----••-•--•-•------------------------------- Owner .,�y � BY c.. _ ...................... ... Title .. _..... �7.�...:.:....... . { (If of e t an'owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.8Y .................... . ... ......Z . --------..-._.........------------.. DATE _...- _Q. _7i:. ..... ........ BUILDING PERMIT ISSUED -------- ------------------ ....................... ADDITIONAL DATE ......................................... ADDITIONAL COMMENTS ...-•----------------•--------`--_.__...._....-•------••- ............. ..................................... ........... . .--- ................ • ------------ -- ...... --------- --- l --•---. Final Inspection by ..............Date r F /..... SAN JOAQUIN LdCAL HEALTH DISTRICT E. H. 1-3 241•'48 Rev. SM 7/723.,4