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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' ---------------------- ---------------------------- Permit No. (Complete in Triplicate) ------------------------------ ------------- ------------ Date Issued 75) 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 Count Ordinance No. 549 and existing Rules and Regulations: _�l - ---- ----- ,� JOB ADDRESS/LOCATION ._ ___ CENSUS TRACT __________________________ rw --------------------- Ownershone -Q - Name /lit - ------ Address - - -------- City r ------------ / �1 - lri �! r =License # / ----- Phone T f��' -SP._0- Contractor's Name ----------- -- -------------- -- { 3+ Installation will serve: Res idence ,P+partment Hou`se'❑ 'Commercial ❑Tr'ailer Court ;❑ Motel ❑Other -------------------------=�-— -------- V - R /4 Y' x-L- - -- ---- wNumber\.of living units:----- Number of bedrooms _______Garbage ind _p_____ Lot Size __________ ____ __ I � Private ❑ Water Supply. Public System and name __________________ _ Character of soil to a depth of 3 feet: Sand Silt El Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Y Fill Material _`_-.-____. If yes,type ----------------------------- 1 S (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,) Np PACKAGE TREATMENT { ] SEPTIC TANK _ _-_____ Liquid Depth ---- --- -------------- Sze ' q p 2— Capacity -- ---- - Type Material-� _ No. Compartments ----------_--�- -- Distance to nearest: Well _______________________...... _..... Foundation ---eo------------ Pro�Line :-__ -- Length of each line-____� -_--'------- Total Length ____________________________ LEACHING LINE X No. of Lines 'D' Box ____�_ Type Filter Material _ ---Depth Filterr Material -----I-e---------- --- Distance to nearest. Well -------------------„_ Foundation _-__l_ __..___--- -- Property Line. ---- ...... PIT Depth ._------ Diameter _ -__.___ Number ____-c7 -.------- -- Rock Filled Yes No i❑ �• `" -------Rock Size Water Table Depth ------------------------------- ____-Foundation Pro Line _ Distance to nearest: Well ---- --------------------•----•-- �-Q----- ----- P• REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic ___-__--- .------------------Septic Tank (Specify Requirements) ---------- -- ----- ------------ ------------- ------------- ----------=--•-------- M . -- - Y - - - ------ Disposal Field (Specify Req.uirem - .----------------------------------------------------------------- --------------------------- ------------------------------- ---------------------------- { ------------------------------- k ------------------------------ --------------------------- :A----- -j--------------- --------------------- (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 -- -----------------w Owner - ------------- ------- Title --------- ------------------------ BY -- ------- (If other th n owner) '� s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - lr - DATE ----- -- - ---- - - BUILDING PERMIT ISSUED --------------------------------- ----------- ----------- D ------------------------------------------- BUILDING - ADDITIONAL COMMENTS _ _ Z _�`--------- !----------------------------- --- ------- ---------------------------------------------------- ---------------------------------- ----- -------------------------------------- -- ---- ------------- -------------------------- P Y _ _ _ Final fns action b Date - SAN JOAQUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'S8 Rev. 5M