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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i li ----------- ---- - Perm it No.'7 3 b-- ii (Complete in Triplicate) - ----- S',. Date Issued II ---------- This Permit Expires 1 Year From Date Issued ----------------------- r 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 Count Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N . rl w2/---- CENSUS TRACT -- Owner's Name --------------- - ----- Phone ---------------------- ----------- Address --------------- 1 - -- ----- - ----- - ------------ City - - ---- -- - --------------- ----------------------------------•------ Contractor's Name --__ _ --_-- - - --- �- :---------.License # -1 Y Phone ----------------------------•- I tatallation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ / Motel ❑ Other ------------------------------------------- Number of living units------1----- Number of bedrooms __ __-Garbage Grinder ------------ Lot Size _._ — -•- = ' Water Supply: Public System and name ----------------------------------------- -----------------------------------------------------------Private Character of sail to a depth of 3 feet: Sand'❑ Silt F1 Clay Peat❑ Sandy Loam ,n Clay Loam 0 Hardpan ❑ Adobe-F-1 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' r!� -___-------- Material-----'---------------- No. Compartments ------------.-. ------ O0Ca -acy- -------- -----_- Typ -______ Distance -to nearest: Well ------------------------------------Foundation --.:_-:-------:____-- Prop. Line -----------------.•--- J LEACHING LINE [ ] No. of Lines ----------I--__-____-.-- Length of each line---------------------------- Total Length ----_-----.--_--.-._----_.. 11 'D' Box ------------ Type Filter Material.__-___--__-__-----Depth Filter Material -------------_------_-_--_--_-__-.-_--- li ;____. ------- Property Line ------------- Z Distance to nearest: Well -______--=------------- Foundation ------ SEEPAGE NT [ ] Depth ------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C Water Table Depth ------------ --Rock Size -------------------------------- i �( �. Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ----------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------------- -1 dc i7 Septic Tank (Specify Requirements) --------- --------- ------ --------------------------------------------- Disposal Field {Specify Requirements) = ' ` --- ---� ------------- . --- �� ----- --------- ------ ------------I- -/-�� 'r 6 - ----------- I'---- •-------------- ------------------- ----------------------------------------------------------------------------------------------------------------------- ----- ii {Draw existing and required addition on reverse side) I!1hereby 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: '1 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 Wor n's Compensation laws of California." i -- ---------- Signed -------------------------- f------------------- -- Own er - - ---- By ------------- Title ........ . --- -'--- --- ----------- (If other than owner) V FOR DEPARTMENT USE ONLY ` DATE ' `�'Q`�J------------ APPLICATION ACCEPTED BY ---------------- ------- - 7 BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------ ---------DATE -------------•---------------------------- ADDITIONALCOMMENTS --- -------------- ------------------------------=--------------------------- ' i -------------- ii ------------------------------------------- --------------- -----------------------� ----- ------ Final Ins ection b Date --- ------ J'-- ------ Py �C ----------------------------------------------------- ------------ �; SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M