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FOR OFFICE USE: i APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) - _ Permit No. -----_----__ t -------- - ------------------ ----------------------- F __________________________-___._____._--_._.___________ This Permit Expires IYear From Date issued d Date Issue _ _2_--�3 Application is hereby made to the Sari 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: { O JOB ADDRESS/LOCATION . -, l _G1fG ------------------- F _ -------------------CENSUS TRACT . t - Owner's Name ._/_AiVj 7K----Z4�_/A #------------------------------------------ -------Phone _ Address ---------- � ...... ------ -------------------- Cit j Contractor's Name ---------4-�- - i_-_�®�L_�----------------------------------License # r� 4�_�a__ Phone o- Installation will serve: Residence 5f Apartment House-[] Commercial:MTrailer Court ;❑ Motel ❑Other ---------------------- ------------------- R Number of living units:----- Number of bedrooms ____________Garbage Grinder ------------ Lot Size __ US - ------------- Water Supply: Public System and name ------------------- ------- -----------------------------Private ❑ Character of soil to a depth of 3 feet: SandE] Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ 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 septictankor seepage pit permitted if public sewer is available within 200 feet,) �� k PACKAGE TREATMENT { ] SEPTIC TANK (5-_-X'? [ ) Size----- �� ___� ________ liquid Depth __�_�_______•_.___,_____ Capacity Ad-- -Q--- Type Rzz� � aterial No. Compartments ---�_____. � Distance to nearest: Well �_______ _ f - ----------------------Foundation - '-6-------------- Prop. Line ........... LEACHING LINENo. of Lines Length of each lin f-------___- Total Length ,__-______ [ ) g D' Box __€_�_____ Type Filter Material _r�i�o%, _______bepth Filter Material _ fes___ _---------------I........------ Distance to nearest: Well ------------------------ Foundation __ _______________ Property Line ,fd_ _______._.. JIi Depth .._ ------ -------- Diameter r_ ------ Number.- ------------------ Rock Filled Yes ET-'--No i❑ Water Table Depth ------------ - ---------------Rock Size ------------------------------- - - --------------- f, - Distance to nearest:'Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------..__------------1 t Septic Tank (Specify Requirements) --------- -------------------------- --------------------------------••----------------------------=---------- -- --- Disposal Field (Specify Requirements) -----------------------_---__--------------------------------------------------------------------------------------------------- I ------------------------- ---- ------ - ---- --- ------------------------------- - --- -- ----------- ------------------------------------------- -------------------------------------- (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 tp Work an's C pensa 'on laws of California." Signed ----------- -------- ---. Owner By ---------------------------------------------------- ------------------------------------------------- Title ------------------- (if' other than owner) ----------------------------------------------------- FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- ---------------------------------- DATE ---- I BUILDING PERMIT ISSUED --------------DATE --------- ---• ------ - ---------------------- t ADDITIONAL COMMENTS -------------- ; i -------------------------------------------- ---------------------------------------- ------------------------------------------- ------- ------ _ ----- I Final Inspection by: = Date -----------�------ --"�--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M