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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT l (Complete in Triplicate) Permit No. .7. .:.. _.... r/i................ ................ ... .............. .. • . This Permit Expires 1 Year From Date Issued Date 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 Ord idb e�No:T344 and existing Rules and Regulations: ll f _.U�`y.:�� fJ JOB ADDRESS/LO TION I-t �?'�'i r ............ ---• -....... ---------------- --.-.--�-- ...-. .CENSUS TRACT Owner's Nome •i- ....................---------;....... ---.. ..... ..Phone ...-----... ................... Address f�..... City - -- • ....--- ....... ...... .........•-......---•-----•••--•••••-• Contractor's Name ...... .. - ----.License # ............. ...... Phone ............................. Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 ` Motel ❑Other ... ----•• Number of living units:..... Number of bedrooms !;i�_..__Garbage Grinder. ............ Lot Size.... _ 5 .. ... .... Ja Water Supply: Public System and name .............. ------ Private ...-- --------------- Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ If yes, type ............................ i (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 J j Size._.; .-.•..------------------------------FLiquid Depth .-•............................... Capacity .. ........ Type -_--- Material---------------------- No. Compartments Distance to riearest; well ................... ' Foundation ----- -------- Prop. Line ................ . LEACHING LIN[ ( ] No. -of Lines Length of each line.... .. ............. Total Length 'D' Box .... --.. . Type Filter Mat6rial ....................Depth filter Material .................. . Distance to nearest: Well ..............:......... Foundation . Property line ..........._:.._._._� ` SEEPAGE PIT [ ] Depth .. . . .......... Diameter .-------. . Number _..-.----......-•-----.- --._. Rock Filled Yes No — `—Y 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 San Joaquin County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Nome owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which thisermit is issued I shall not I P employ p y an y person in such manner as to become subject to Workma ' Compensation laws of California." 11 Signed ...... .......... ! Owner By . _._.... (I other than owner) Title . .................... ....... ............. .............. fOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y .� / ..._.._.----,- DATE . b .'fJ' . BUILDING PERMIT ISSUED --.......... . ...-----------.........----- ........... - .- ---- .... ..............DATE _..---...._._...._..._ ADDITIONAL COMMENTS _--------------�...... ------------------------ ....._...----- --------------.... - -•---• -- ..._........ -•--------... ---------------- .--. ------------. ...... ---------.,.....-------------------- Final Inspection by: -•--- .•• = - `. ! _.. Date . .. J --------- SAN JOAQUIN LOCAL .HEALTH DISTRICT r E. H.13 241-'68 Rev. SM 1 1.71'1 U