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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------ ------------------ -------- (Complete in Triplicate) Permit No. - ------------------ --------------------- ---------------- This Permit Expires I 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 Counntty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . - - �?* CENSUS TRACT Owner's Name l! 1,7 = Phone/ Address 3-13-6 t j -----------. City ' �" ,' ' A Contractor's Name ___-- _ - ��-�__ _ -�" ----��---.License ----- Phone ------------------------------ Installation will serve: Residence [E Apartment House�[] Commercial ❑Trailer Court i❑ Motel ❑ Other ------------------------------------------_ Number ------ ------------------------- Number of living units:---- ------ Number of bedrooms __ .....Garbage Grinder ---_-------- Lot Size ___ _ --------------- Water Supply: Public System and name -------------------------------------------------------------------------------------------- ------------------Private ,[1 .Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom Clay Loam I 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,) W PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ----------------:----.----- 16� Capacity -- ----------------- Type -------------------- Material---------------------- No. Compartments -------- ............. —4 Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------------- 41 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 ____-_.-____________________-...-_] SepticTank (Specify Requirements) --------------------- -- -------------------------------------------------------------------------------------•--- -------------------•---- D'sposol Field iSpecify Requirements) '-- -----�---- -- ;?1Z11 (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�.�+✓y ---------- ----------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------=------ -------- -----------. DATE ---'S k!-ZZ--------------------- ---------------------------------------- BUILDING PERMIT ISSUED ------ - - --------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS - ------------------------ ------------------------------------------------------------ ----------------------------------------------------------I- :-------- J _____________________________________________ _ ________________ _______________________________________________________________________________________________________________________ __ _ _________________________________ ____ ______________ _____ _______________________________________________________________________________________________________ Final Inspection by ' --------------------------- --------- -----------------------------.Date _5-:- --- - ------------ s SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1268 Rev. 5M