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I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in`Triplicate) Permit No:--------------------------------------- ------------------ ------------ This Permit Expires ] Year From Date Issued Date Issued F 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 Ordinance No. 549 and existing Rules and Regulations: f JOB ADDRESS/LOCATION . - ----------- Poc leedj - CENSUS TRACT --•-------- Owner's Name ------------ y -- -- - --- - -------------------------- -- - - one Address = L - -- - -- - -----'City..- - - -- ---- - Contractor's Name - ----------------- ., to ' - License❑# Phone - ----------- installation will serve: Residence_ Apartment House❑ Commercial:- Trailer Court ',❑ Motel ❑ Other Number of living units:--=---- Number of bedrooms -----Garbage Grinder-_ Lot Size _-- Water Supply. Public System and name ___ _________________ �'" - -------Private El- ------------- Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Clay ❑ Peat-E] Sandy Loam ❑ Clay Loam;❑ Hardpan ❑ Adobe Kill 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'[ l Size------------------------------------------------ Liquid Depth ------------------ Ca acit ' - p Y --=-'-- --------- Type ----------------- _4Material--------------- ---- No. Compartments -- -------------• Distance to nearest: Wel! -------- ------------Foundation ---------------------- prop. Line ---------------------- LEACHING LINE [I. No, of Lines -------------__------ Length of each line.----- -------------- ------ Total Length ----------- `.,:D'.Box ----1------- Type Filter Material ----------- --------Depth Filter Material --- ---------------------- Distance to, nearest: Well ------------------------ Foundation -------------- --------- Property Line __ ----------------•----- SEEPAGE PIT [ ] Depth ------1___---_ _ _-- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth -----:------------------------------------------Rock Size ---- ----------------- Distance to nearest: Well ---------------------------------- -- -Foundation -------------------- Prop. Line ------------------_ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------_--_____) E Septic Tank (Specify Requirements) --------------------- Disposal Field (Specify Requirements) _-_----ado--------- ---0 - __--e -------------- -- -- ------------------------ ------- ----------------------------------- ----------------------------t- -" 4' __A, -------- -------------- ----------- - -------------------I ___ 2__1___' ---------- r-- (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 ofsthe work for which this permit is issued, I shall not employ any person in such manner as to become subiect-to-Workman's Compensation laws of California." Signed ---- ' --- - ------ ------------•------------ caner BY --------- ----- --- - ------ � ---------- - Title -----; - wn -- - - ---------------- - - ------------------------------- ------------------- o er t owner)--"- wner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- --- _ ---- --------------------------------------------------- DATE BUILDING PERMIT ISSUED -- ----- -----}-_ DATE ADDITIONAL COMMENTS --___--------------_____ ,_--_ ------ -------------------------- ---------- --------------t--- --- ---------------------------------------- --------- ---------------------- - -------- --------------------------------------------------- --------------1 Final Inspection b �, ,z - - �1 --------------- P Y .�-------_�-:-,-� -- ------------------------------------------------.Date ----- � --�•l�--�, YO�--- ------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT fff E. H. 9 1-'68 Rev, 5M. �