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FOR OFFICE USE: . x APPLICATION FOR SANITATION PERMIT ------------- Permit No. (Complete in Triplicate) . /4 - : -.. 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 madelin compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOC ON . _{p O l� -�_. ._'___CENSUS TRACT -------------- Owner's Name __ ' -------------------------------------------- ----Phone .---------------------------.-------- - ----- -- ----- Address ---------1 (p l f� -- ----- •-- ---------------- City - - - ----- ----------------------------------------- f Contractor's Name ---- �`� '' ------------------------License # /1 ' Phone ------------------------------ ,; Installation will serve: Residence [� Apartment House,❑ Commercial ❑Trailer Court ;❑ � `Motel F-1 Other -------------------------------------------- Number --- - --------------------------------- Number of living lunits:____1______ Number of'6droomsc ________Garbage 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 ❑ 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: {N septic tank or seepage pit permitted i� ublic se der is available within 200 feet,} Q� _ i PACKAGE TREATMENT�,[s SEPTIC TANK'[ Size- ___/ __ __1S------ _____------ Liquid 'Depth ----5�_-_._-------------- Capacity ___________- I � Ca aci �-.G� Type _ __________ ___ _ _ Material__�No. Compartments. r l Distance_,to Weare Well ------------ -------Foundation -------?_k-__o------ Prop. Line -----Is LINE ['. No. of Li es ------ ------------- Length of each line-------IP --- Total Length �O�-___________- 'D' Box __ _ __ -._.Type Filter Material ____S__R.v___Depth Filter Material ---L1___t-______-----------7--------- ._ Distance nearest: Well ------------------------ Foundation ------------ Property Line. __ ...____.___�� SEEPAGE PITS [ Depth _._ ` _�______ Diameter __�__,3_t.___ Number __--_.____ ---------------- Rock tilled Yes No i❑ Water Table Depth ----------lk--r----------------•------------Rock Size ------ Distance to nearest: Well ---------------l__Q e' Foundation ---- t-P •--- Prop. Line ------n.-......---•- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________________________________} SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------:----------------------------------------------- DisposalField (Specify Requirements) --------------- --------------------------------------------------------------------------------------------------------------------- -------------------------=------ - - ------------------------------------------ ------------------------------------------------------------------------- ---------- --- --------------- -- ---------------------- E (Draw existing and requi'ed 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 awner or licen- sed agents signature certifies the"following: "I certify that in the performance of the-work for which this permit is issued, I shalt not employ any person in such manner as to becosu ject to Wo man' Compensation laws of California." p. Signed ---- -------- --- Owner 1 BY --- Title Title ---� 4�t '� Q----------- --'-!J-*--------------- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- -- ------------------------------I---------------------------------- DATE l ''- ----------------- } BUILDING PERMIT ISSUED ----------------------------------------- -------- DATE—-!-,--, ADDITIONALCOMMENTS ------------------------------------------------------------------------------- -------- --- ------------------------------ --------- --•-`-------------- _____________________________________________--_._..______.-----.____-------- __________________________________________________________________________________________________________________ ---------- ______________._---------______._.___._-__-_______;_ ____----____ _ _ _____ ________ __ _ __ _:___-___ Final Inspection b.y: ----------------------------------------Date --------- �. SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'6$ Rev. 5M