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it FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- s Permit No: . -3 (Complete in Triplicate) ----- ------------------------ -------------------------- - p ' Date Issued -.-_- ----------- ---------- This Permit Ex fires I Year From 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 commp?liance with Counfi f,dinance No. 549 and existing Rules and Regulations- Y5 +r` �� - CENSUS TRACT - �� JOB ADDRESS/LOCATION -_-- ----------------------------- Owner's Name -._ ------------------------------------------------------------Phone ------------------------- -------- Address ----- '�,$ - -- ------ - ---- - ---------- City -- '! -------------------------------------------------- !3 --- ---- - - - Contractor's Name ... -------------------------- ----- ------ ----�-- -I! �. License #�1� ---------�' Phone Installation will serve: Residence [impartment House❑ Commerc'a ❑ Court i❑ Motel ❑Other -----------I------------------------------- Number of living units:------I.... Number of bedrooms --_.Garbage Grinder ---_----- - Lot Size --------------------------------------•----- Water Supply: Public System and name ------------ -------------------------------------------------------------------•------Private Character of soil to a depth of 3 feet: Sand'n It❑ Clay E] Peat E] Sandy Loam ❑ Clay Loam '[:] Hardpan (Adobe-F] Fill Material ------------ If yes, type ---------------------------- (Plot --- ------(Piot plan, showing size of lot, to 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[.] Size------------------------------------------------ Liquid Depth -------------------- Capacity Type J------- Material---------------------- No. Compartments ------ ------ Distance to nearest: Well ------------- - --------Foundation ---------------------- Prop. Line ----.----------------- v1 LEACHING LINE [ ] No. of Lines ------------------------ Lengthk of each line------------------------- - Total Length ---------------.------------ n , 'D' Box ------------ Type Filter Materia€� --------------------Depth Filter Material --------------------•-----------•----•...... Distance to nearest: Well ------_---------------- Foundation ------------------------ Property Line ------------------------ r SEEPAGE PIT [ ] Depth -------------------- Diameter ------_r--------- Number ---------------------------- Rock Filled Yes ❑ No ❑ ,5 Water Table Depth ------------------------------------------------Rock Size ----------------------------•--- I Distance to nearest: Well ------------------------------------------Foundation --------------- ---- Prop. Line -----....-------___--- REPAIR/ADDITION(Prev. Sanitation Permit# ---- - 1------------------- Date ----------------------------------) SepticTank (Specify Requirements) ------------------------------------ -- ------------------ ------------------------------------- --------------------------------------------- Disposal Field (Specify Requirements) +, .---=--- ------ 21� �� --- --- - - �' --- -- ----------------------------------- -------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and.Ah,at 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 11cen- sed agents signature certifies the following: "I certify that in the performance of the work for which thii permit is issued, i shalt not employ any person in such manner as to become subject to Workman's C ensation laws of California." Signed ---------------------------------------- Owner Title . - i--Y- ------ell, --- . .� (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------- ----------------------------------- DATE ---------------- BUILDING PERMIT ISSUED ----------------------- -------DATE ---------------- ------- -------------------------------------------------------------------- ADDITIONALCOMMENTS -----------------------------------------------------} -------------------------------------- ------------------------------------ ----------------------------------------------------------------------------- ---- --------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- -- ------ --------------------- -------- ------ ------;---------------------------------------------------------------- 1 ----------- ---- Final Inspection by: ----------------------------------Date - --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i� E. H. 9 1-'6B Rev. 5M j