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JFOI� f-FICE USE: APPLICATION FOR SANITATION PERMIT --------------------- --------------------------------------------------- ----7�f- -�- --- (Complete in-.Triplicate) Permit No: - --------------------- _-- s (� [- '✓ This Permit Expires 1 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_s� __� �__ _ _______--- ----CENSUS TRACT ___ V_____ Owner's Name ------------- ta�I /•----- --------------------------------------------- ------Phone-r' J� L' Address --------- '� t,��f C? S C -� r�r------------------_---_. City - V::2,� ----------:--------------------------------------------- Contractor's Name ------------------ -----------------;--------------------------------------------.License # ---------.-------------- Phone ------------------------------ Installation ------------------------------ Installation will serve: Residence . partment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number --- -- - ------------------ -- Number of living units:------/-___ Number of bedrooms _ -----Garbage Grinder Lot Size ___ -- __ Water Supply: Public System and name -------------------- ------ - ------ ------------------- ------------------ ------Private ❑ Character of soil to a de th of 3 feet: Sand' Silt -£I p ] by ❑ Peat❑ Sandy Loam ❑ 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,) PACKAGE TREATMENT { ] SEPTIC TANK[ ] Size-----------------------------------_------------ Liquid Depth -_-_______----_..-__,__..- Capacity -------------------- Type -----. Material-------------- -- No. Compartments -----------------:.... .r Distance to nearest: Well _________________________________Foundation---------------------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines ________________________ Length of each line.--------------------------- Total Length ----------- .......... 'D' Box ___________ Type Filter Material __________________Depth Filter Material ----------------_...-........._--_,_,..:- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ___.____-____-_-- : �/ SEEPAGE PIT [ ] Depth -------------------- Diameter _-__-____-___ Number _ _________ ___________-_ Rock Filled Yes ❑ No i❑ 1 Water Table Depth -=----------------------------------------------Rock Size -------------------------------- Vy► Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... i. REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- Date _____---____________--__-.-----•__) Septic Tank (Specify Requirements) _______._ _____ ._ --______ _ v - / -r= lR---s .. ------- -------- Disposal Field (Specify Requirements) 1 � �'� ------- --------------------------------------- -------------•---•--------------- ---------------------------------------------- ------------------------------------------------------------•--------------------------------------------------------------------------------------------- (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 be.ot sub'ect o orkman's Compensation laws of California." Signed ------ -- ------ ------------------------------------ Owner BY -------------------------------------------------- ----------- - ----------------------- Title ------------------------------------------------------------------------ - (If other than owner) FOR DEPARTMENT USE ONLY ----_. DATE ^�, APPLICATION ACCEPTED BY --------- "-- ----- ----'-- -- ---- ---- ----- -------------------------- ------- - --------- - --------------- -^ --------- BUILDWGPERMIT ISSUED -- ------------------------------------------- - -------- ------- -----------DATE ------------•----------------------------- ADDITIONAL COMMENTS ------ ----- - -- --------- - - --- - ------ -------------------------------------------------- ---` - - - -- -- / ----- ---------------------------------- Fina) Inspection .+► - - -----------------------------------.Date ----- --------------•------------ -•------• SAN JOAQUIN WCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M