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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ...... (Complete in Triplicate) ............... ............................ This Permit Expires 1 Year From Date Issued Date Issued _ ." 4-7y 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 madein compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO /2 �V ..._.i �..._._.... .......-----............•--..............._......•---........:CENSUS TRACT .......... ........ Owner's N me ....... �. . ............ h . •----------------f---••---•...... .• ..:.__Pone . Addressf:Je AA".,�-�:._.��.... City `..... ::.:........................:......:'.. Contractor s Name - License # ............................ ••--...._•-•--........... .......................... Phone .._...::.' ................... .................. ., Installation will serve: Residence, Apartment House 0 Commercial ❑Trailer Court 0 E Motel ❑Other . Number of living units............ Number of bedrooms ..u7.-------Garbage Grinder .______-- Lot..Size. ....................... Water Supply: Public System and name ........____ ...............................:_..Private Character of soil to a depth of 3 feet- Sand❑ _Silt❑ Clay ❑ - Peat❑ Sondy Loam } ] Clay Loom ❑ Hardpon,M Adobe:E] Fill Material ............ If yes,type ----------- -------------- z (Plot plan, showing size of lot, location ofsystem in relation to' wells, buildings, etc. must.be.placedon reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available-within 200 feet,} 3 PACKAGE TREATMENT [ j SEPTIC TANK-[ ] size-------------•--•---• T ... Liquid Depth ............. Capacity ---- Material................. No. Compartments !+ •................... Type --•--•---•----•- .... -----=---........ Distance to nearest: Well ..............................Foundation ...................... Prop. Line ..-.. ........... tip J LEACHING LINE [ j No. of Lines ........................ Length of each line.._..-__-__..------- Total' tengih -- 'D' Box ............. Type Filter Material ....................Depth Filter Material Distance to nearest: Well ........................ Foundation ---_--_-....: Property Line •...---::_:.-=----=--::. SEEPAGE PIT [ 1 Depth --------------------- Diameter ................ Number- --------..-............ stock Filled .- Yes 0 No 0 Water Table Depth .......Rock Size Distance to nearest- Well........................................Foundation .................... Prop.,line ....................... -- REPAIR/ADDITION(Prev. Sanitation Permit# Date ................................... } Septic Tank (Specify Requirements( ..................................�i.......-•-------•--...:..'...--••----•-._............................... ._:.-------00 of--.--------------- A Dis osal Field {specify Requirements} w_ -. i�r._. _ •_- .---_: Y r (Draw existing and required addition on reverse side}, 1 hereby certify that l 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 liceh. sed agents signature certifies the fallowing: "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 become �subject ,to W man's Compe tt laws of California." Signed Owner Title _.... - BY :.......................................... n �..= .............. ................. ••------• ------.._.. ...................:............... {If other than owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . -------- I............... -r ........ DATE d._. .. . �........... . . BUILDING PERMIT ISSUED ........................................ :.... --.:..-_......................••_...-----......DATE --•---. .....--•-- •. ADDITIONAL COMMENTS "' ""' ......................................................k•................................. .................................................. -.-1----------- - ..... ...--- .....................•---------••--..........----•- f r j v _ .............- .......... • .......................................•_.... Final Inspection by y7� ..........................•- -- ....._.__... .. . ----•-•----------------- --•--••---•-•------••-------- ..._... . ----..........Date �? lf�.......... . SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241-'b8 Rev. 5M 71-rq z