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k FOR OF;�. USE: PLICATION FOR SANITATION PERM`T / 1J r L, rmit No. --------------- \'�` (Complete in Triplicate) } `=------------ -----•- ----------------- Date Issued --- I -- . This Permit Expires 1 Year From Dates e o. Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: .-CENSUS TRACT ---•-----•----•-------_-- JOB ADDRESS/LOCATION r,S---- - --`- ---------------- Owner's --Owner's Namre. -�._---.---• -----------------------------------------P one ------------------------------------ ----------_---------- -----•- ?- ----- ------- u4Address City --- --------.-.License # - Phone ------------------ Contractor's Name ------ •- ----------- - installation will serve: Residence Ap artment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other ------------------------------------------ t of living units:-----1------ Number of bedrooms __:3__...Garbage Grinder ------------ Lot Size --------------- Private ' Water Supply: Public System and name ------------------------- ---- ---------------------------- Private Character of soil to a depth of 3 feet: Sand'❑ S't❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe ❑ Fill Material ------------ If yes,type ---------------------------- {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_p"ublic sewer is available within 200 feet,) (AJ Liquid Depthth ---------------------••- PACKAGE TREATMENT SEPTIC TANK Size Ca acit ------ 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 f=ilter Material ---------------.---------------------------- N _ Foundation Property Line ________________________ Distance.to nearest: Well _-------_--_"-----_--- -------------- --------- PIT [ ] Depth --- Diameter ---------------- Number --------- --------- ------ Rock Filled Yes ❑ No Q Water Table Depth .-------Rock'Size -------------------•------- Distance to nearest: Well ---------------------- - ----------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit+ -------- ----------------------------------- Dote -----------------------------------) Septic Tank (Specify Requirements) ---------------------- -"------•----------------------"--------------•------------- ----------- Disposal Field (Specify Requirements) ----- --------------------------- ------------------ ----- -------- ------------------------- -- ------------------------------------- -------------------- 1 (Draw existing and required addition on reverse sidel 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------- -------- Owner BY ..... ------ ------------ Title -------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y . - ------ ----------------------------- = DATE -�� 3 ��----------------•- BUILDING PERMIT ISSUED ------------------ ------ ---------- •------------ DATE ADDITIONALCOMMENTS ----------------------------------------------------------- -•-••------------------------ ------------- ... _ ------- -------------------------------------------------------- -4, -- ------ ------- -- ----------- --------- ------------------------ ---- ---- -----Final Inspection b Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'S8 Rev. 5M