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I FOR OFFICE USE- APPLICATION APPLICATION FOR SANITATION PERMIT ----- Permit No. ---- (Complete in Triplicate) -' - ----------------------- ------------------------- ------ --------------------------------------------------------- -------------------------------------------------------------- This Permit Expires 1 Year From bate 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 omliance with County Ordinance Na. 549.and existing Rules and Regulations: JOB ADDRESS/LOCA N ._.Jr -- --- -------------- ---------------------------------------------CENSUS TRACT ---------------------- k Owner's Name - - --------- --- - r_ - --:-------------------------------------- Phone ` Address ------ u '------ ----- City -: - ----- -- J . Contractor's Name - License# _� ef'_37� Phone ______________________________ Installation will serve: Residen ( Apartment House❑ Commercial:❑Trailer Court ❑ Motel ❑Other-------------------------------------------- Number of living units:____- ___ Number of bedrooms __3____Garbcge Grinder ____________ Lot Size __________________________________________ o 4, Water Supply: Public System and name -------•-------------- ---------- ------------------- -------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'7 Silt 1] Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam 2r," Hardpan ❑ Adobe-❑ Fill Material ------------ If yes,type ___________________________ y (PI'ot 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) I� PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------ `-----------------_- ------- Liquid Depth -----------.__--_....-•-.• "1 Capacity --------------------- Type -------------------- Material---------------------- No. Compartments ----------------- %9M Distance to nearest: Well ----------------------- ------------Foundation ------------ --------- Prop. Line ....__.._ ......... ` ,.r LEACHING LINE [ ] No, of Lines ________________________ Length of each line__.-------------------------- Total Length 'D' Box ____________ Type Filter Material ____--------------Depth f=ilter Material .___________________._-____-_----_.-__-.---- Distance to nearest: Well ------------------------ Foundation ------------------------ Property line. ------------------------ SEEPAGE PIT [ j Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes '❑ No 1❑ Water Table Depth -----------------------------------------------Rock Size ---------------_-_ Distance to nearest: Well ----------------------------------------Foundation --------------_.---- Prop. Line ...................REPAIR/ADDITION(Prev. Sanitation Permit#------------------ ________________________ Date ________-___________________._._.} SepticTank (Specify Requirements) ------------------------------------------------------------------•------------------------- ------------------------•-•- --•--- --------------------------------- posol Field (Specify Requirements) �. `.. ? ------------------ - -- ----- (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 to Workman's Compensation laws of California." Signed --------------=------------------- - --- ------- Owner ------------ -- - ----- --- � ,�f By -------- ------------------------------ '--- -- ------ - - - TitleLfJ ,f� '---------- -- - (lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B -7!_ __ -Z 7C7 - -. DATE _ `S BUILDING PERMIT ISSUED --------------------------- - ------------------------------- ---- ----------=-------------_DATE --------------- -------------------------•-' ADDITIONAL COMMENTS ---------------------------------•-- - --------------------------------------- -- --- --- ------- - ------------------------------------------ -- - ---------------------------- -----------------------------------------/ ----- t SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'G8 Rev. 5M,