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FOR OFFICE USE: _ I APPLICATION FOR SANITATION PERMIT --- -- ---------------------------- Permit No:��_'t�'_�-�`J5 (Complete in Triplicate) This Permit Expires ] Year From Date Issued Date Issued -------------- ------- ---------- ------------- Application is hereby made to the San Joaquin Local Health District for a per 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 _7___ - --- - --- ------- 1_ ------------ ----------------.-- -------CENSUS TRACT ---------------•- -- Owner's Name - -- --- ------ -------- ---- - - -- ----- --------------------------------------------- --- - Phone -----------------1- .-----••--- Address -----------�C-� - Cit ----------------------•---•-- ^ Y aa Contractor's Name -- License # ��G�. ------ Phone ------------------------------ Installation will serve: Residen a Apartment'House�❑ Commercial :❑Trailer Court-0 Motel ❑ Other .------------------------------------------- Number of living units:------ Number of bedroomsg -o'�______Garba a Grinder ------------ Lot Size ---------------------- ----------•-------- Water Supply: Public System and name ----------------------------------------------------- ---------------------------------------- _______________Private, i Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam f Hardpan ❑ 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: iNo septic tank or seepage pit permitted if public sewer i s available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ----------------- Liquid Depth 4/________._-___-_____ O 4$ap Material- No. Compartments Capacity TYPe i P -------•-- i Distance to nea est: Well ____/__0�1_ ___________________Foundation --_�Q_------------ Prop. Line ___- ______:________ LEACHING LINE [ No. of Lines --------------- Length of each line---- Tota! Length ------_____________•-- 'D' Box -hnearest: Type Filter Material ----5 ,--- -Depth Filter Material -------L-f- ---------- ---------------- Distance Well ------1.t'4'-__"_- Foundation -----� _........... Property Line - -______________ SEEPAGE PIT [ ] Depth -------------_----- Diameter ________________ Number ---------------------------- Rock Filled Yes .Cl No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ---------------------------------"-----.Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------- ------ Septic Tank (Specify Requirements) _________________" ._ --------------------- Disposal 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 Son 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 ollowing:"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 became ioer ' to Workman's Compensation laws of California." Signed ------------ Owner BY - ------ - -- Jitle . ----"----------------- - ---- ------ ---- ( than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ ______________ -------------- ----------------- DATE _ - J" -._-•------------------- BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE --------- --------------------------------- ADDITIONALCOMMENTS ------------------------------------------------- ------------------------------ ---------------------------------------------------------------------------- ---------------------------------- -- - --- T ------------------------------------------------- -------------------------------------- ----- Final Inspection b ____________________________.Date .... __.. _ ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. SM