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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------- - Permit No. ------------- (Complete in Triplicate} - ---------------------------------------------------------- '"� Date Issued 7o __________ _______________________________--------------- This,Permit Expires T Year From Date Issued ' . t 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. l � JOB ADDRESS/LOCATION ---- !_- __ � - _________________CENSUS TRACT __________________________ Owner's Name i - � Y ---------,I-i --- ---Phone ----_------- = Address ----------------- - •5- ` . ' cry. City - -------------------------------------- Contractor's Name _..�—�_-_-_�_� _- - __ _____� - ______.License # 7 __ Phone ��lP �l�L Installation will serve: Residence �partment House❑ Commercial :❑Trailer Court ;C] Motel ❑Other --------------------------------------- Number --- -------------------'-_Number of living units:--- Number.off bedrooms _s�_____Garbage Grinder _____ ___ Lot Size __�� `�--_____________ Water Supply: Public System and.name._L��'Jy> l�ss4 Private ❑ - ;- - i, Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ] Hardpan ❑ AdobeX Fill Material ------------ If?es,type -----~'_'----------------- (Plot __._-,____-_____(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,) h PACKAGE TREATMENT ( I SEPTIC TANK f ] Size---------------------------------------- Liquid-Depth -------------------------- `n 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 ❑ Water Table Depth ------------------------------------------------Rock Size -- ------ ----- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line- -i'-------------- REPAIR/ADDITION(Prev. Sanitation Permit# --------- --------------------------------- Date ________--_---__-_-_-__________.,_I Septic Tank (Specify Requirements) ----------------- - --------------------- Disposal Field (Specify Requirements) __ __ ----------- -- - ------------- ------ ------------------------------------------------ ----------- ------------------------------------------------------------ ------------------------ ------------- - ----- �dition ---------------------------------------------------------------------------------- (Draw existing and required 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 bec a sub ect to Workman' ompensati.on. s of California." Signed _ ----- - -- -=---------- Owner - ---- ------------- -- - - - By ---- ---- ----------- ------- ---- --------- -------------------- Title ----------------- - --- ----- - (If oche han owner) ORD RTMENT USE ONLY d APPLICATION ACCEPTED BY ------ -- ------------------------ ------- DATE ----- ---- -- --�-----------•--------- - ----------------------- ------------- BUILDINGPERMIT ISSUED ---------------------------- - - - -------------------------------------------------=------------DATE ------------------------------i ----- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------- ------------- ---------- ---- ----- ----------------------------------------- --- --------------------------------------- ---------------------------------------------------------------------------------------- --- - ---------------------------------------- -------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------ - - - - - - - - --- - - - ----- Final Inspection by: " Date - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M