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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .. -- - --------- —' 3 ----- This Permit Expires 1 Year From Date Issued Date Issued _7"1 -____.- Application is hereby made to the San .Joaquin Local Health District for a permit to construct and install the work hereir. described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION = ------ `--'-. ----- ` { - ---- -------.----. --CENSUS TRACT Owner's Name _.-__-- - - ----- -- - -- --- --- ------------ --- .Prone ._ AddressL l , ------------ City , . . ..-- - ---------Contractor's Name - License----=-- Phone --- Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other Number of living units:.. _-�__--- Number of bedrooms .___Garbage Grinder --- _ Lot Size _.. r• ----------- Water Supply: Public System and name -------- --------------------------------------------- --------------------------- --- Private Character of soil to a depth of 3 feet: Sand ❑ Sift❑ Clay [] Peat❑ Sandy Loam L?` Clay Loam ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,J f PACKAGE TREATMENT [ j SEPTIC TANK'[ Size.--'" - - Z. ---- ------ ---- - Liquid Depth Capacityf .. -_./fte-� Type ? t.C. �•j Material No. Compartments --------- �/ Distance to to nearst: Well ._------_�5--��_____ __ ________Foundation --- --- -� Prop. Line -.__ LEACHING LINE ►J [ No. of Lines `'' `-- ---------- Length of each line ----.--�rr Total Length ,S 'D' Box Type Filter Material ---- --------Depth Fil�er/) aterial __---_�� - -__--_ Distance to nearest: Well ----------- Foundation __--_ Property Line _ #_ _.__ SEEPAGE PIT Depth --- cz _--� _- Diameter `- =_f£--- Number ------ ,t Property -------- 9 Rock Filled Yes No C Water Table Depth ----- -------- �-" -, ------------- Rock Size .. - _ Distance to nearest: Well _- _ -------------Foundation _ _...---_--- Prop. Line --- Z_ _ _ --- ✓ REPAIR/ADDITION(Prev. Sanitation Permit# ___------______ ---- -- --- -- -- Date - ------ --- ---------- -------1 w Septic Tank (Specify Requirements) -__- ___. -- DisposalField {Specify Requirements] ----- ------------------------------------------- -----•-------------- -------- - ------ -------- ------- -- --------------- - ------------ -----------------I - (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: "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 Workma 's Compensation laws of California." Signed ----- ---- ----- Owner ----- - r ---------- Title __ . r € I other than owner} r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y BUILDING PERMIT ISSUED ------ , r z a r ---- ----- - --- -- ----- -- -- -------- ---- DATE _---_-�a„?___---- --_- ADDITIONAL COMMENTS - - --- -- -------DATE --- ------- ----------------- ----- y---------- ----- ------ ------- -- --- ---- --------- -------------- -------------- -- --- - ------ --- -- Final Inspection by: __- _- y,. -- ---------------------- ---- Dat- w a=- ---------- - - - - -- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M