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r FOR OFFICE USE. Y ` 3 APPLICATION FOR SANITATION PERMIT ----------------- ----------------------- Permit -- ---------- pTriplicate) Permit No: . =tet` 1'; (Complete in ----- -•---------=-- --------------- -- ----- - - ---------- •------.._' _-__.----_----- This Permit Expires 1 Year From bate Issued Date issued Application is hereby made to the San Joaquin Local Health District for a permit oto construct and install the work herein. described. This application�is made in compliance with County Ordinance No)549 ,and exisfiing,. Rules�alncl Regulations: t JOB ADDI2ESSj10 ION .__ � _ - ---- _ -----------Xy ----CENSUS TRACT Owner's Name --------- ne - [ Address --- -- --- ...... ..l --- -------- City -` Contractor's Name ---------------------- ----------------- ----- --------License # -------- ------ Phone - --------------------- - 4 Installation will serve: Residence p1rPartment House❑ Commercial ❑Trailer Court Fj Motel ❑Other ------------------------------ Number of living units:------------ Number of bedrooms _ ------Garbage Grinder ------------ Lot Size ------------------------------------------ Water ---------------- - ---------------------Water Supply: Public System and name ----- ^'P __-----_ " - -------- - Private Character of soil to a depth of 3 feet! Sand' Silt❑ Cla ❑y eat—❑Sandy Loam -C] Clay Loom E]Hardpan❑.Adobe_❑ terial_-_Fill Mas lY.e), tYpe � ,� - (Plot plan, showing size of lot, location of system in relation to- wells, buildings, etc lmt betplaced on reverse side-) f us _ NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGIs TREATMENTC 7- ASEPTIC TANK'[ l Size--------- ----------------------------s----- -- Liquid Depth -------------------------- J Capacity - -{---------------- Type -------------------- Maferial---------------------k,.,No�Comp artments f Distance to nearest: Well ----------------------------A-----_Foundation ------------_--------- prop. Line .------------__------- J LEACHING LINE [ j No. of Lines Length of each Yline. ------------ Total Length ----------------••--------- D' Box -,-!------- Type Filter Material -------------------Depth Filter Material -------------------------------------- Distance to nearest: Well ------------------------ Foundat-ion---:•�,-__. -- t-_____ Property Line -___._-_-._-__---:---- rn SEEPAGE PIT [ ] Depth ----- ------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ "No i❑ ' Water Table Depth ------ Rock Size -------------------------------- Distance to.`nearest: Well ._____---------------------------------Foundation -------------------- Prop. Cine ----------------- -- REPAIR/ADDITIO. Nm -------------------------------------------- ------------------ Septic • roF Date ------------------ } Septic Tank (Spify itequiremerfs) -------------- - Disposal Field { pecify Requir�m ts) ____. ® - _ _ r _ `ox ---------�-_ __ _ �_�. -------------------1_ 4 --- ----------------------------------------------------------------.. ------------------------------------------------------ -- . (D.raw.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 beta blect to Workman's C mpensation laws of California." I Signed �� ----- Owner By - ----------- --------------------------------------------------------- ----- Title --------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED i3Y -- -- -------------- -- -- -- ------------------------------------ ------------------------- DATE ------------- BUILDING PERMIT ISSUED ------------------------------------- ----------------- ----------=--------------DATE ADDITIONAL COMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- --- - 4- --- A4----------- ------------ Final Inspection by: -- -- -�_ ``"�"�--- -- ------------------- -------- - -------------- -- ---------------.Date-- ------ -7 ---........ .=------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9"'F 1-'6$ Rev. 5M