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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT '_] - �� -------------------- Permit No. _1177 (Complete in Triplicate) This Permit Expires 1 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: ZJ }} JOB ADDRESS/LOCAT -- ----------- � . -I� --------------------------- -------------------- CENSUS TRACT --. Owner's Name - --- -------- --- ---------------------------------------_ ----------------Phone---------------------------------- Address , -- J_ �' City ----------- ° -- — - Contractor's Name --ems (---- L'--.License # Aff-. Phone ---------------- ---- Installation will serve: Residence Apartment House❑ Commercial : Trailer Court ;❑ Motel ❑Other --------- ----------'- -------------------- Number of living units_--I_----. Number of bedrooms - ---Garbage Grinder -------:---- Lot Size ---- ---- Water Supply: Public System and name --------------------------------------------------------------------------------------------- Private Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam,E-1 Hardpan ❑ Adobe ❑ Filr l 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ! PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size--------------------------------------------------Liquid Depth _--- _-----------W Capacity -------------------- Type -------------------- Material-------- ------------- No. Compartments -----------•----------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------_--------------- LEACHING LINE [ ] No, of Lines ----------------------- Length of each line --------------------------- Total length .------------ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---=----------------•-----------.------•--•- • Distance to nearest: Well ----------------- ------ Foundation -------------- --------- Property Line ------------------•-- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No 0 WaterTable Depth ------------------------------------------------Rock Size --------- ---------------------- Distance to nearest: Well ---------------------------------------'Foundation ---=-:'------' --- Prop. Line --------------_----- REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------------w------- "r`` Da#e -------------------------------- ) b SepticTank (Specify Requirements) --------- ---- ------------------------- ---------------------------------------------------------------- ---------------------------- Disposal Field (Specify Requirements) -- - -- ---- � --- ---- ---------------- -----I---C- d--- - ------- - -- - -- --- -- fV1 -------- Q---- --- --- - ------ ----- -- ---------------------------------------------- --------------------------------------------- (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 become0sub'ect to Workman's Compensation .laws of California." Signed -- -___ Owner r BY Title `� ' - V (If other than owner) OR DEPARTMENT- USE-ONLY APPLICATION ACCEPTED BY ------------------------------------------------------------------------- DATE - '- I--------------------- BUILDINGPERMIT ISSUED --------------------------- ---------------------- - -------- ;----- -------------------------------DATE ------------------------- ------ --------- ADDITIONAL COMMENTS ------------------------ - --------------------------------- ------------------------------------------------ ----------------------------------- -------------- ------------------------------------------------------------- --------------- --------- ------------------------------------------ -- - ------------- --------- ------ -------- ------- --- Final Inspection by: ----.Date _l."_-.-----_�-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M