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h A- s • FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No� (Complete in Triplicate) -----------------------------------------_--------------- This Permit Expires ] Year From Date Issued Date 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 -------- - - -- ---- -- -------CENSUS TRACT --.----- -Owner's Name -------- ----------------------------------- -- Phone 13�!�� ------------- ------------ CityAddress ------------ - i qc� Contractor's Name --- • .----------------------------License # - -c16--- Phone _�_3• _" �71... Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court i❑ Motel ❑Other ------------ ----------------------------- Number of living units------I----- Number of bedrooms 3-----Garbage Grinder . _ Lot Size _- _ _______ ____________________ Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Si it❑ Clay. ❑ Peat❑ Sandy Loam.[$ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ---IVP--- If yes, type -___.___.._______________ (Pl'ot 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 [ ] SEPTIC TANK N Size-fQ_;� - - -a-S- ------------------ Liquid Depth ------!�11------------- 0J Capacity A5760------ Type MaterialNo. Compartments ------ Distance to nearest: Well -------f.-0....................Foundation ------- Prop. Line _____ 0 LEACHING LINE LIN NA No, of Lines ________..3_________ Length of each line--------- ,D_ -_.__.__- Total Length ___.Z7,c'��____-_.__ 'D' Box __li'- Type Filter Material - 1 . -±____Depth Filter Material ----at�'_��- _ -- - ------------------ Distance to nearest: Well ____7s`___________ Foundation __--Z- -------------- Property Line ------- SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ O Water Table Depth ------------------------------------------------Rock Size ----------------------•--------- Distance to nearest; Well -.__--________-_--____________________Foundation -------------------- Prop. Line ---------- REPAIR/ADDITION(Prev. Sanitation Permit K# -------------------------------------------- Date -------------------------------_-_} G Septic Tank (Specify Requirements) ___________________._________- -------------------------------------------------------•--------------...------------------------••- 1n 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. 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 become subject to Workman's Compensation laws of California." Signed ---- ---------------------�j-----------------------------------n------------------------------- Owner By ---- ( - G� ----- '"---------r'------------ If other than ow1/0, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -BY ..7F7 .!:-1U---------------------------------------------------------------------------- DATE --- _Q C-------- BUILDINGPERMIT ISSUED ---------- --------------------------------------------------------------- --------------DATE ------------- ----------------------------- ADDITIONAL COMMENTS ------------------ -- --------- - --7--- 1 a ---------------------------------------------------------------------------- :. ------------ - ----------- -- -- - -- f ------ Final Ins ction by: --- - ---- Date --- [.-'� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M