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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..��`..� .............................................. This Permit Expires ] Year From Date Issued Date Issued _4 .. 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 egulations:JOB ADDRESSAOCATION ... - _ - .. ✓._.._ _.... CENSUS TRACT .......................... Owner's Name ................ .. ........._........_-�-:.._.—_._......___......................._..,._..----•--•----. . _ .. ......-.Phone ........._..._..-•---...... Address --------------- -------- -- �----. ._.__.... 7 � City Contractor's Name ------- . ._ ..._-. .,_.-License # .lt.� .�� .? Phone .............................. Installation will serve: Residence �portment House❑ Commercial ❑Trailer Court 0 Motel ❑Other .......................................••... Number of living units:------ _... Number of bedrooms ....3..Garbage Grinder ___________. Lot Size ____________________________________________ Water Supply: Public System and name -------•............................_...--...._...-......_ ------------------------------------------------Private [� Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom 0 Hardpan ❑ Adobe.IJ Fill Material ------------ If yes,type ................... {Piot plan, showing size of lot, location ofsystem 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,J PACKAGE TREATMENT [ ] SEPTIC TANK i ] 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 0 Water Table Depth ..............................Rock Size ... ............................ Distance to nearest: Well .........................................Foundation ----................ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit Y# _----------- ............................. Date .................................. Septic Tank (Specify Requirements) —......................................................................... ................ .................... Disposal Field - (Specify Requirement1s) ...--•-•------•-•----••--•-------- -----------• - ...._.....: --------------------- CLi—je- a ----_------------------- .---_ -...- ........................ ---------------- ----------------------------- (Draw existing and required addition on reverse side) I hereby certify that Lve 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 Son 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 .. .. . '`-v' 4 By ................................... _ ........ �J� _. � Title ....... .-- (If other than owner) _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... _ _._. . DATE - BUILDING PERMIT ISSUED ..................... ......................DATE ADDITIONALCOMMENTS -----------------------------•-•-• ................................. ------.__..._._._._._..__-------------..__.__....____.------------------_...-----. ...... ............................. •-----....••--- ------------------•--•----•-•.......... Final Inspection by: _.. --•--•-------•-•--••-•-••-----••--••-•-•-•---•-•--••------Date"- a`. ................... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.1-3 241-'68 Rev..5M 7/72 3 IA