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FOR oF1cI= USE- APPLICATION FOR SANITATION PERMIT ' Permit Na. ------------- --- --------------- ---- ----------------- ;Complete in Triplicate) J - , ---------=-------- ------------------------------ 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. l r JOB ADDRESS/LOCATION ------z0 V /CENSUS TRACT -------- --- • fes► Phone ---- Owner's Name .- { l ]/y1yt �� Address -------- - City 14AN .� ----- -------------------------------------- Contractor's Name �A---�,.r� --------------------------------- ----.----- Lice Installation Phone - . Installation will serve: Residence ❑Apartment House-❑ Commercial XTrailer Court i❑ a Motel ❑ Other - ------------------------------------------ Number of living units------------- Number of bedrooms ------------Garbage Grinder --------- Lot Size �--------------•------ Water Supply: Public System and name ---------------- ---- -----------------------------------------------------------Private 5a Ai Character of soil to a depth.of 3 feet: Sand; Silt ElClay E] Peat E] Sandy Loam [l Clay Loam 0 Hardpan ❑ Adobe ❑ Fill Material ------ If yes, type ---------------------------- (Plot .---e---------------------(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 -------------- ' - •1 Capacity ---- --------------- Type -------------------- Materi 1---------- No. Compartments Distance to nearest: Well ----------------------------- ------Foundatio --------------------- Prop. Line ---.--------------•--- LEACHING LINE [ ] No. of Lines -------- ------ Length of ea 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 l❑ Water Table Depth ---- ----- -------- ock Size ------------------ ------------- Distance to nearest: Well --------- _ ..Fou ion -------------------- Prop. Line ..-.------..----..---. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---- --- ------------------ -- - ate ------- -------------------------- Septic Tank {Specify Requirements} -= ----------- Disposal Field (Specify Requirements) ------------------- 1��t ------------------ ------ ------------- --- --- ----- ----------- �. ---- ----0-.X- x g = - = (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 i County Ordinances, State La%(s, 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 of2 the work for which this permit is issued, II shall not employ any person in such manner as to become subject to Workman' Compensation laws of California." Signed6-, -- -----' ---------------- ---- ---------------------- Owner By ------- ---- Title ------------------ ----------------------------------------- ----------- f other thaK owner) �—� FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY 1 '`��-------------- --------------- DATE BUILDING PERMIT ISSUED --------------------- -- -------DATE ------------------- - ------------------------------------------------------------ k ADDITIONAL COMMENTS ------------------- - -- ------------------------------------------- -------- ----- --------------- ------------------------------------ ----------------------- -----------' ------------- ------------------- --- - --------------------------------- ----- --------------- -------- ---- Final Inspection - Date -.. - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT + r u 0 1_'AR Rav 5M