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FOR OFFICE USE: ' ................................................ APPLICATION FOR SANITATION PERMIT r (Complete in Triplicate) Permit No. .��_-._. .. ........................... �...._.-_. This Permit Expires 1 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 County Ordinancip, No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA ION ._.- - .-.._(/ - ....... .... ... .. .......CENSUS TRACT .......................... Owner's Name,: - Phone ftolar �f� ._._. Address y. A .a-. .� -------------------------_....---.. - CitY .................................. ...__...... Contractor's Narne�. f................� .-_----.License # ............. Phone ._...-.-._..... .............. Installation will serve; Residence Apartment House C] Commercial ❑Trailer•Court r Motel-❑ Other .......... ................................. Number of living units..... T_ Number of bedrooms .__ g __Garba a Grinder ...._..--..- Lot Size ..__ . ............. Water Supply: Public System and name -._.----- ---._:--------------------------------------------------------------------_.__..._..Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [] Hardpan ❑ Adobe L_ 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,) 1� PACKAGE TREATMENT [ ] SEPTIC TANK j Size................................................ Liquid Depth .......................... +s Capacity ........ Type -------- ---------- Material--........ -- ------ No. Compartments ................. Distance to nearest: Well --- .-- ----------------Foundation --.._- .......... Prop. Line ___--------••--- .... 00 LEACHING LINE [ j No. of Lines ... Length of each line.......... .... .___. .... Total Length _.._.._.-._........___....... 'D' Box ._-._. Type Filter Material ..--------- _ - ___----Depth Filter Material ............................................. Distance to nearest: Well ........................ Foundation .- ..---.-i.. Property Line -----............. .__... SEEPAGE PIT [ ] Depth ......-_ Diameter ----------- ---- Number - --- .- _. Rock Filled Yes ❑ No [] � r, Water Table Depth - ............ --------------------Rock Size -------~----------------------- Distance -- ----- ------ Distance to nearest: Well -----•--------------- ------Foundation ............. ....... Prop. Line ---- ................. } REPAIR/ADDITION(Prev. Sanitation Permit# ........ ..................................... Date ---------------------------------- 1 Septic Feld (Sifeceq Rements)quirements) - ------------------ --- ----- • ,....-. ---....---- _..�_...-•---•----................-.-- Di ---..._. ....... � - R_ rements) G� - -- � ................. --- ... -.------. ................................... (Drdw•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 bec me ject to Workman's Compensation laws of California." _ .E , OwnerSigned O •--- BY : I ---- ---- -- ...................... - Title . ... (If other than owner) -1 _ FOR DEPARTMENT USE ONLY F '` APPLICATION ACCEPTED BY .-- ----- t©: ......------------ DATE _/O .. �' 'f - 7 $BUILDING PERMIT ISSUED -------------- ----------- ----------------- -- ------ ------DATE . .......:t............ , .4 ADDITIONAL'COMMENTS .................. ................................--1------- ....................... •- --------- ---------------------------------- -------------•--------•.._._..----•--•--•-........ i ........................... -• -- ;'Final Inspection by: -.-- �. ..............................Da I SAN JOAQUI LOCAL HEALTH DISTRICT V