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NI FOR OFFICE USE: �¢ � APPLICATION FOR SANITATION PERMIT --,�-3 _ ____6(Complete in Triplicate) Permit No. ______________JThis Permit Expires IYear 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ ------CENSUS TRACT ---- Owner's Name --- av�'e e?----- ------------------------------------------------------Phone _ Address ��= �' -'------------ ---------------------------------- - --------------------. City 1 Contractor's Name -- - -�-�-„' Z _ '�"------------------------- --------License # Phonel ( Installation will serve: Residencepartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other Number of living units:______._ Number of bedrooms __ Garba a Grinder - Lot Size _ Water Supply: Public System and name ' ._ �-_ 4e Vie__--------------- -----------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe Fill Material ------------ If yes, type __________________ (Plot plan, showing size of lot, location of system in:-relation fo 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'[ 7 Size------------------------------------------------ Liquid Depth --:------------- - p Capacity -------------------- Type -------------------- Material------------------ No. Compartments F Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line __________...._____---- LEACHING LINT: [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material Distance to nearest: Well ------------------------W Foundation ------------------------ Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number ------ --------------------- Rock Filled Yes ❑ No ,0 Water Table Depth ------------------------------------------------Rock Size + Distance to nearest: Well --------------------- --- - -------Foundation --------------- ---- Prop. Line ------------------- REPAIR/ADDITION .---------------_- -REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date Septic Tank (Specify Requirements) ----------------- Disposal ---------------Disposal Field (Specify Requirements) ---- ' -- ..._ ------ r T - - -------------------------------------------------- ---------------------- (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 kCaunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: .1 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 ----------------- ---- ----- -f----------------- - -- - ----------------- --- ----- ------ Owner - BY (if er than owner)r) "----- ------------------------------ Title ��1�� --------- o PAfRTMENT USE ONLY APPLICATION ACCEPTED BY -------- - --- - ----- ----- --- -- DATEBUILDING PERMIT ISSUED DATE - _� ------------------ ADDITIONAL - - --- I i - - -- ADDITIONAL COMMENTS - ---- ----- - -------- __ __ ______ __ --------------------------- -------- ---- - - ------- - - ---------- -- ----- -------- ---------------------------------------------------------------------------------------- Final ins ection b le-------------------------- p Y ' ----.Date = SAS JOAQUIN LOCAL HEALTH DISTRICT cam_ E. H. 9 1-'6$ Rev. 5M.