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FOR OFFICE USE: _ T - APPLICATION-FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------ This Permit Expires I Year From Date Issued Date 1 Issued 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: JOB ADDRESS LOCATION Owner's Name- -----------.,,CENSUS TRACT -------------------------- s Address �— P or; � = " b- ' ��-- F = -- --.----- Q,� city ti � Contractor's Name .01 License #f14 ------ ��------ Phone ,��:_ Installation will serve: Residence Apartment House❑ Commercial-❑Trailer.Court ❑ � Mote! ❑Other - ---------- Number of living units:__-- ___.__ Number of draoms � ' �a fir` ____Garbage Grinder ____:_ _____ Lot Size 1 ------- Water Supply: Public System and name -_ � . y :. =' ----- - Private ❑ Character of soil to a depth of 3 feet: Sand' ilt'[] Clay .EJ Peat❑ Sandy Loarn ❑ Clay Loam Hardpan ❑ Adob TFill'IVlaterial�_-- --if,yes,---",t}ipe'--------------------------- - (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 TREATMENTgg [ ] . SEPTIC TANK[ ] Size ` 1 ------•----------------------------- Liquid-Depth -------------------------- Capacity -----------=----- Material 1�J I ' V 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 i ----------------------- Distance to nearest: Wel! _ ® ------- Foundation Foundation ___ Property Line p_ SEEPAGE PIT [ ] Depth ______ _ ________ __ Diameter __ Number _ Rock Filled Yes t No Water Table Depth --- - ----------'____Rock Size - ------------------- - I } Distance to nearest: Well 12 ?_______________________ ____Foundation { - - -- ---------- ----- Prop. Line ---------•-•---- PAIR ADDITION{Prey, Sanitation Permit# ________________________-- } - ti-- Date --- -------•-------------------- Septic Tank (Specify Requirement s) ------ ----- --- - _ %J -------------- -------------------------- Disposal Field (Specify Requirements) ------t;;g�-- -- ------- -- - -- ------------- 40-1 ---a-------- ----- (Draw existingand re aired addition on reverse side, I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licenin- 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 become subject to Workman's Compensation laws of California." Signe - ------------- --------- ------ -----•--- -------------------------------------------------- Owner By .. ------------------------------------------------- -Title - - If other than owner) -- - --------- t i FOR .DEPARTMENT USE ONLY APPLICATION pTION ACCEPTED BY _ r - - - BUILDING PERMIT ISSUED DATE y_- 1-------------------- ADDITIONAL COMMENTS -------------- -i- --------------------- --DATE ------------------------------------- -- ------ ----- ------ ---------- - ------- -------�- - -=-------------- i - -•---------------------------------- --------------------------------------------- ------- ------- ------------------------------------------- -------------r-- ---------- Inspection b Final Ins - - p y ------------------------Date fix'I ------ --------- f SAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1268 Rev. 5M