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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I Permit No. ------------------------- ---- ----------- ----------- (Complete in Triplicate) --------------------------------------------------------- Date Issued ---- This .-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 County Ordinance No. 549 and existing Rules and Regulations: 1 - �� C� TRACT�---- -,-o�l° �JOB ADDRESS/LOCATION .- ---- -- .............�- ' g- R --- --- hone Owner's Name -- •------------ ------ --- -` s---- � I 1 - ------------' -------------------------- ----- s ------ fT� ` _-----.._. C;tY � ------•-- Address ---.----------------=------- �!_- �-lQ _� - - Phone ----- -----------• --------- Installation Name ------------------ ',.�h1-��-IZ.,,----- -----"------ ---------- ---- ----- -----------License # --------- ----- -------- i Installation will serve: Residence JRApartment House'❑ Commercial ❑Trailer Court .❑ Motel ❑ Other -------------------------------------------- Number of living units:-----{----- Number of bedrooms ---7;�-----Garbage Grinder ---------- Lot Size ---------------------------- - , tPrivate ❑ Water Supply: Public System and name ______L�1_-�-_�• ----------------- - ---------------------------------------------------------------- ----- Character of soil to a depth of 3 feet: Sand'IN Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam :❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- (Phot 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,) IN PACKAGE TREATMENT [ ] SEPTIC TANK Size------------------------------- Liquid Depth ---------------- i z" ------ Capacity ]2�_�!1)_-- -- Type ---------------=---- Material�r^�'�. No. Compartments Distance to nearest: Well ------- ---- =----------------------Foundation ---------------------- Prop. Line ------------------•--- LEACHING LINE No. of Lines -----�2-------------- Length o each line----------- -�- ---- Total Length 't 41 ,------- - �- 1 'D' Box _ - _ Type Filter Material 2-, 6__Depth Filter Material -------fl ------- Foundation ------------------ Property Line. ------------------------ " Distance to nearest: Well ______________ _ ----- M1 SEEPAGE PIT [ ] . Depth ._ ---------------- Diameter ---- Number ---------------------------- Rock Filled Yes {] No C WaterTable Depth ----------------------------------------------- Rock Size -------------------------------- t Foundation -------------------- Prop. Line ---------------- Distance to nearest: Well ----------------------------- IDate ------------------------- REPAIR/ADDITION(Prev. Sanitation Permit ----------------------------- Septic Tank (Specify Requirements) ______-_.._______________ __ ---------- ---------------------------------------------------------------- , Disposal Field (Specify Requirements) ---------- ---------------------------------------- ----------------------------- _ _--_-__I------------------------ ----------------------------------------------------- -----"-.-_-_________-_._------------.--: ----------------------------------------------------- -----------------------------------------------------`-----------------------------------------------------------------' {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 becom subject to Workman's Compensation laws of California." Signed__. Owner Title ------- ---------- - ------- --------------------------------- --------- BY (If other than ownerj" FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-- ----.L et-------------------------------------------------------------------- DATE ..: __` -------------- i ,-- DATE ------------------------------------------- BUILDING PERMIT ISSUED ----- -- ---- --------- -- ----------------=----- ADDITIONAL COMMENTS - _ ��-�-{------ ----------- � -�--= - fi` ----------------- - --------- - --------------------------------------- - .Date ---�/-.�--' '----------------------------- Fina Inspection bY --------- ------------ SAN'JOAQUIN LOCAL HEALTH DISTRICT F H 9 1-'6$ Rev. 5M