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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. 54 *9� and existing Rules and Regulations: y�� ws --- t ---CENSUS TRACT `-�q JOB ADDRESS/LOC TION/ ----✓- --- - -7.___ F Q ----.Phone ------------------ ------ ---------- Owner's Name t ------------------------------- - ------ - ---- -- Address ---------- ------ 2-1-.- - --- --- 1 } 1 j 1 City s "�''�r ' Contractor's Name ------- ------- - License # .��°de _ Phone Installation will serve: Residence ®�Apartment House-[] Commercial ❑Trailer Court ;❑ Motel ❑Other -------- -------------------- -------------- Number of living units:____ ------ Number of bedrooms ---------Garbage Grinder --------- -- Lot Size _______ --- Water Supply: Public System and name __________________ ____ _ - - ----------------------------------•----- ------Private Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam [P� Hardpan ❑ Adobe F-]/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:1 (No septic tank or see age pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( J SEPTIC TANK[ Size. =- --- -�?-.....X--S-------------- Liquid Depth ------- ----------,----- Capacitytt: Type 1 - - -- Material--__ - No. Compartments ____-;7--Distance tc Weare Well -------------�-Q----=--------------Foundation -------1-�--- Prop. Line __5- ........... LEACHING LINE [fill" No. of Lines 1-------------- Length of each line-------S�---------------- Total Length --------------- 1/ 'D' Box -1------- Type Filter Material ______.S- _-- _-Depth Filter Material -------Y_- If Distance to nearest: Well ---------tP ------- Foundation -------J_P-------------- Property Line. ---r------------ --- Depth ----- 5 -- Diameter ---i-3-"__--._ Number .___.__--y------------ Rock Filled Yes No I❑ De SEEPAGE PIT [� p � Water Table Depth ------------------I-------------=--------Rock Size _/IY__x__r _n........ Distance to nearest: Well ---- ------------ Foundation -----'-a-- ----- Prop. Line _. ~.------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------- ------------------------------ Date ----------------------------------) -Septic Tank {Specify Requirements) ---------------------- ------------------- Disposal Field (Specify Requirements) --------- ---------------- -------------- ----------------------------------- __._. . _ _.i. - ._ ------- ------------------------------------------------------------------ -------------------------- -- _ _ _______________________________________ _______ ___________________________________ _______________ ____________________________________________ {Draw existing and required addition on reverse side) 1 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 i5 issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------- --------- Owner /l �C1.,_�1_llt Title ",-`-e/`�1 ------------ --- ----------------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------------------------- -------------- DATE -.__�-" y'-7----------------- -- BUILDING PERMIT ISSUED ------ ------ -- ---- ----- DATE ADDITIONAL COMMENTS --------------------- ----- ----------------- - ---- -------------------------------------------------- --------- ------- _ ---------- -------------- --------------- ----- _ ___ _ ___ Final Inspection by: __-__ - �' ---.Rate _. ._` -------- - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1268 Rev. 5M