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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- ---------- -- ----------------------------- - No. �'-.'--- -- (Complete in Triplicate) Permit --------------------------________------------------ 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/LO TION --d—'?I - - V r enl J - ' e�lG�r= ------- CENSUS TRACT ----- - Owner's Name .--t-- --�2_�_-p-I&Y--------�4t -0-'e-------------------------------------------- � //: ------Phone Address / ------�- ----------------- City M_0-fYreA ' Contractor's Name [ :. __-- -: f'-" -------------------------------- License 4_�c3,� __ Phone _=12 . Installation will serve: Residence ® Apartment House,❑ Commercial ❑Trailer Court ',[[ Motel ❑Other ---------------------------------__...... Number of living units:.... ----- Number of bedrooms _______Garbage Grinder ------------ Lot'Size �'__l_� ___________ r Water Supply: Public System and name ------------------------------------------------- -------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'[[ Silt❑ Clay [] Peat V--- Sandy Loam ❑ Clay,LoamHard an Adobe Fill Material If es, ._________A ❑ ❑ Y 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 f ] ize_________________________ _-___ Liquid Depth: i Capacity -------------------- Type ---------- ------ Material---------------------- No. Compartments ----------------- Distance to to nearest: Well ___________ _ ____________________Foundation _:_ ______ ___ Prop. Line ----------- .......... LEACHING LINE [ ] No, of Lines _______________________ Len h of each line_________________ _____ Total Length ........... ---------- 'D' Box ------------ Type Filter Mat ial ____________________Depth Filter Material -----------------i---- _Distance to nearest: Well _________ _____________ Foundation __________ _______-___ Property Line ______--_--._.___-....._ I SEEPAGE PIT [ ] Depth ____________________ Diameter Number -------- ---- ___________ Rock Filled Yes ❑ No 1 Water Table Depth ----------------- ------------------------------Rock Size ------------------------------- I Distance to nearest: Well -------- ------------------------------Foundati n -_------------------ hrop.lLine -------------.-....... REPAIR/ADDITION(Prev. Sanitation Permit# --------------- ---------------------------- Date ------ ---.-----------------------1 Septic Tank (Specify Requirements) ------------------------------------------------- . ----1 - ---- Disposal Fi Id (Specify Requirements) ��4 - _��-� c3 � ------------------------------------------------------ --- --------------------------------------------------------------•-------•- --------------- ----------- -- -------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- fDraw 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 withSon 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 Workm 's Compensation laws of California." Signed - -- ---------------------- ------- -------------•---------- Owner By ....... °------ -- ---- - ----------------- Title --- ---------------- (if othe than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ��------------------------------------------------------------------------------ DATE --- --------------- BUILDINGPERMIT ISSUED --------------------------------------------- -------------------- --------- ---------------------------DATE ----- ---------------------------------- ADDITIONAL COMMENT - ------ ---------- - -- -------------------- ---- ------------------------------------------------------------------------------------------------ --------------------- ------------ ----- ----- ---- -- ----- ------------------- ------ --- -- --- ------------------------------------ p ---------------------------------- r Final Ins p = X - -------------------------------------------Date --- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M