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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - --------- (Complete in Triplicate) Permit No. ---------------------------------------------- This Permit Expires ] Year From Date Issued Date Issued -fl-3--_ U 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: i ) JOB ADDRESS/LO TION _ - _-- 1 £�' �----CENSUS TRACT --------------------- -- - Owner's NameYi- � Phone Address -------- - - --- --- -------------- -- City 6ze—a ,---- ---------------------------------------------- Contractor's Name ------- ----.License # � ��- a` ---- Phone ----------------------•------- --•--- Installation will serve: Residence eApartment House,❑ Commercial ❑Troller Court i❑ Motel ❑ Other -------------------------------------------- r Number of living units:-- Number of`bedrooms ________Garbage Grinder ----- .__- Lot Size/7d_a4__jC- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loom ❑ Clay Loam:0 ' 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 public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size-----------------------------------------------Liquid .Depth -------------------------- V Capacity -----------------•-- Type -------------------- Material---------------------- No. Compartments _._.-.....---•-------- -Foundation ------------------- - p• Line ----.------ Pro :------ Distance to nearest: Well ____._______--- ----------------- - LEACHING LINE [ ] No. of Lines ______________________ Length of each line----------_----------------- Total Length 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------I-----------------•-_--- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------- ...... SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------.-----_.. REPAIRJADDITION(Prev. Sanitation Permit# -------------------------------------------- vr r Date ----------------------------- ---/- - GePt (Specify Requirements) --------------------------------- ------------------------------------- - aDsonal Field (Specify Requirements) ) _ ------------------------------------------ ----- ------------------------------------------- ------------------------- ------------------------------------------------------------------- {Draw existing and required addition on reverse side] I hereby certify that 1 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 -------------------- A - Owner 17L ------ -Title .-. By ------ ------ ------- ----- �' ---- --- - ---- - --------------- - (If other than owner) FOR .D1EPAitTMENT USE ONLY APPLICATION ACCEPTED BY .. � ` _------------------------ -_ DATE _/-- ------------------------------------ BUILDING - -� �'-" c�'---------- AQQITIONAI COMMENTS - ------------------ DATE DDITIO PERMIT ISSUED ------- s� �) 3 ----------------------------------------------------------------------------------------------------- ----------------------------------- ------------- -- -------------------------- . r ---- --- - --------------- ------ ----- = - s{ Date _Final Inspection by: _--- - ------- SAN JOAQUIN LOCAL HEALTH DISTRICT S E. H. 9 1-'b$ Rev. 5M