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FOR FFICE�. uSE: _ APPLICATION FOR SANITATION PERMIT / ---- -- -- "-`� Permit No. _- /---: -� (Complete in Triplicate) — --------------------------- - -------- ----- ------- 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 _ - � L � �P�?'� ------------------------- -- --- ------------ ----CENSUS TRACT -_----------------------_- Owner's Name -- ..... •�jl�yf'�F!'I----------------- ----------------------------- ----„�----Phone Address ------ �+� 1,77-e--- ---------------- ------. City ----5-17-16-lelow--------------------------------- Contractor's Name ----_-�_r_ �? ---- --------------------------------License Phone Installation will serve: Residence [4?<artment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units-----/--- Number of bedrooms -An....Garbage Grinder / -_ Lot Size - _-7_________ Water Supply: Public System and name ------------------------------------------------------------------------------------------------- -------------Private ®r- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ 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 ------_------------- 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❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line -------- ------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) Septic Tank (Specify Requirements) -------------- ------..__,._------------- Disposal Field (Specify Requirements) ----- ~ ------ + 1'-- --- /J- ------ ----........... --------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 BY ----- : -- Title ------- ,%'l it---------- ---- ---- ------------------ -------------------------------- -- (If of r t an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------- ------------------------- ------------------------------------------------------ DATE ------ /_-71•-------------- BUILDING PERMIT ISSUED -------- --DATE _____________________ ---------------------- ADDITIONAL COMMENTS ------------- ------------------------------------------------------------------------------------------------------------------- -------------------------- - ------------------------------------------------------------- --- - - ------------ ------------------------------------------------------------------------------ - - Final Inspection by ----------------------------Date _.—�---- 7/-- --------------------------- - - - --- ------- SAN J AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M