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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -_-__.____•----- -- , ---- -- --------------------------- --------------------- (Complete in Triplicate) ------- ------------------------------------- Date Issued ------------------------------- This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations- ---- - 4ldi O -- . --- CENSUS TRACT --- --_- 7---- -.5.. JOB ADDRESS/LOCATION __�3 = -------- _P4'�- ---- L'-i Owner's Namefi Phone.PAi_:r -?�� ---------- Y 4R t4.a0P-------------------------------------------•----- Address __f.�-C}_�__�_�� ----f-�-------------------------------------- --. Cit _ - = - a" p� - Phone . Contractor's Name License # -- 7 - -- r Installation will serve: Residence Apartment House-F Commercial:❑Trailet Court i❑ w Motel F1 Other --=----------------------- -----------•---- `n Number of living units------------- Number of bedrooms:------------Garbage Grinder ------------ Lot Size �r '!��r' ---------------- Water Supply: Public System and name --------------------- -------------------------- Private Character of soil to a depth of 3 feet: Sand'® Silt C3Clay ❑ Peat❑ Sandy Loam El Clay Loam ❑ Hardpan ❑ Adobe-[] Fill Material ----- ------ If yes, type ---------------------------- k (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,) Liquid De th --------------- PACKAGE TREATMENT { ] SEPTIC TANK,( ] Size___________________________._--___._ q p - Type -------- - Material = o. Compartments ----------------- Capacity0 ' Distance to nearest: Wel! ------- _ ---- ----Foundation ----- --------------- Prop. Line --------- ------------ ---------------------LINE [ ] No. of Lines ------------------------ L gth of each line-------------------- Total Length , ------------- 'D' Box --- - -- Type Filter M tenial --------------------Depth Filter Material ---------------------------- .--•--• r I Distance to nearest: Well _____ _ ______________ Foundation Property Line ____-______--___.--_____ L 1 ----------- --- -------- SEEPAGE PIT [ ] Depth ----f---------- --- Diamet r ---------------- Number ------------ ------- Rock Filled Yes ❑ No WaterTable Depth ------------ -----------------------------------Rock Siz -------------------------------- ------•-••--- Distance to nearest: Well __ ------------------------------------Found ion ---_.____.------- Prop. Line 1 REPAIR/ADDITION(Prev. Sanitation Permit# ________ _____ Date _- ------------------------------ Septic Tank (Specify Requirements ) ---------------- ---- ---------------1 -------- 4 ' Disposal Field (Specify Requirements) --- t$it/L------- -- ----- ---- ---- ---- . "�' . ----- - ----------------------- P------------- _ _____ --------------------------------------------__----------------------------------- ----- - ------ {Draw existing and required addition`on reverse -side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------------------- ----------------------- Owner -------- - -- - - Title ------------------------ ----------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By ------ --------- ---------------------------------------- ------- ---------- DATE ------2----7 BUILDING PERMIT ISSUED ------------- --- ----------------------------- ---DATE -- ----------•----------------------------- ADDITIONAL COMMENT --- - ---------------- --io ..----------- ----- ----------------------------- _.. --Date .--- � Final Inspectio ' ! SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M