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�FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - Permit No. - (Complete in Triplicate) ---------- Date Issued This Permit Expires 1 Year From 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 Coun y Ordinance No. 549 and existing Rules and Regulations: vVC,I - - JOB ADDRESS/LOCATION .--- CENSUS TRACT -------------- I ----Phone e?"--Z>�3_-------•. Owner's Name -- --- ---- } -------------- - iCity ---- . ---------- ------- Address ---- -------- J'- --- �-- - -- - --�------------ ----------•--- Ce 1 ------.License # 5-- : y3----- Phone Contractor's Name ----------------- --- -- - -- --- Installation will serve: Residence�KlApartmedt House❑ Commercial ❑Trailer Court 'El Motelr❑Other -------------------------------------------- Number of living units:___-_(___. Number_of�b`drooms:- ________.Garbage Grinder ---_-------- Lot Size ---- ---------- Water Supply: Public System and name --------- ------- -------- 4 Private Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay El Peat❑ Sandy Loam)6 Clay Loam Hardpan 0 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 seepaget,pittpermitted if public sewer is available within 200 feet,} SEPTIC TANK' Rc` `� e----�1-�-A---------------- Liquid Depth __ PACKAGE TREATMENT [ ] � --------- T, •---.--.. Capacity � _ - :-_ Type -- - ------- ------- Material__---- No. Compartments ---___.-__. _ Distance to nearest:z,:1W11t _____ --------- -- Foundation ---�0--- ------- Prop. Line __. _r_..-•-_ 1ST I } 7Q - -- Total Length------Z�!--.-----••---• O LEACHING LINE ] No. of Lines _---___----.-_� Length of each line__--___ . g E —T _-___De Depth Filter Material ___l_________________----------------- y _ ___ _ _ 'Q' Box ------� Type Filter Material -e__ ___ _ , Distance to nearest: Well -lab-------------- Foundation ----- 0_.Y`_-------- Property Line. Depth Diameter t______________ Number _._____._____-____-________ Rock Filled Yes ❑ No i❑ SEEPAGE PIT [ ] p ---/--- ___________ _____ Rock Size _--- Water Ta61e_De Depth _ ---------------------- - -------- ------------------- Distance o nearest: Wel - ------------------ Foundation. Prop. Line ---------------------• fl- ' - REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------- -------- } Septic Tank (Specify Requirements) -------------------.---------------------------------------------------------------------------------------- Disposal Field (Specify Requirements} s ---------------------•--------- �r s`---- ------------------------------ ------�------------- - t fI (Draw existing and required addition on reverse side) 1 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- 4 sed agents signature certifies the following- �- "I certify that in4he performance of the work for which this permit is iswed,i shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." ,Signed - -------- ---------- Owner - - V r Title ---- -- --------- -- ------------------------------ --------------- By --------- V (if other n owner) « FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ �` - DATE ------- ------- ----S�- ----------------- --- --- - ---- -- ------ ------------------------------- B'UILDING PERMIT ISSUED ------------------------- --------------- DATE - - AQDT1`IONAL CONIMZNTS ---" �- ------------------------------------------------------------------- --------- --- -------------------------------------------------- r -� ---------------------------------- --------- ----------------------------------------------- ----- ------ --- = ------------------- Jf'' j= ----------------- ----- t--------------`?`--- Date -. - ---- - ----- ----- -------- --- Final Inspection by: ____-_4 -_-____-- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M