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I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT f- f t Pe.mit No. e.. -z-,: + - (Complete in Triplicate) _ ......................... ..............-- ..... This Permit Expires 1 Year From Date Issued Dote Issue _�r.:............... 1, Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal} the work herein 1t } described.This application is made in compliance with County Ordinance No, 549 and existing Ruies and Regulations: JOB ADDRESS ACCATION .,i S F 7 `� �^� �Z _...CENSUS TRACT - .71 �t . - - Owner's Name ......... ....Phone.._ .................. 5sa s ��/ ....... --- Address - L LG' ------------.City rcr�........................ ...-.-- �-�-±c ._q0._icense#_/ .5 :.- Phone .- Contractor's Name...._ "'t'=t''___ '" ,-- - .....-------- Installation will serve: Residence dApartrnent House❑Commercial OTrailer Court ] Motel❑Other.. -------------------------- Fi Number of living units:..... Number of bedrooms .^ -__--_-Garbage Grinder .c ,.- Lot Size ..e:9=.. Water Supply: Public System and name ............ ..----- ...-- -- - --- ---................... ........- ......Private 2— Character of soil to a depth of 3 feet: Sand F] Silt❑ Clay ❑ Peat❑ Sandy Loam ff� Clay Loam(� F Hardpan EDAdobe E] 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.) i (j NEW INSTALLATION: No septic tank or seepage,pit permitted if public sewer is available within 200 feet,) t r i t PACKAGE TREATMENT [ ] SEPTIC TANK j Size----------------------------------------- Liquid Depth ...-----------.........--- Capacity ... Type------------------- Material..-- -- -- - - No. Compartments ...................... �+ Distance to nearest: Well ...................................Foundation--_._...............Prop.Line_................-__ } LEACHING LINE ( ] No. of Lines ............ . Length of each line............... Total Length 1 'D' Box __...-.... Type Filter Material ....................Depth Filter Material .....................------------........... Distance to nearest: Well ........_.............. Foundation ........................ Property Line ..............__._....__ SEEPAGE PIT [ ] Depth .................... Diameter ................ Number _-__-_-- Rock Filled Yes ❑ No ❑ Water Table Depth -------------------_----.------------------Rock Size................. Distance to nearest:Well .......................................foundation Prop. Line ----------- ...... �i REPAIR/ADDITION(Prev.Sanitation Permit#-------- ---------------------------- Date ... ..........--._-----__-_] Septic Tank (Specify Requirements) .-....... - ........ --.......... .................-------................................. _ ------ --- ----- Disposal Field (Specify Requiremen ) 0_0': - .... � -... .................... (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 liven- sed agents signature certifies the following: 1 "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner 6 as to beco a svbjed Signeto Workman's Compensation laws of Colifarnia." d... .:........._.-- _ _ Owner �. •C.._..._-- Title -... f1 .�tsS f [P�a...................................... ti (If other than owner) � ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B .---__ ............... DATE_�'�.�.....�..�b- BUILDING PERMIT ISSUED ------ -- -- - ------- ...... - ---................--------- ---- --.DATE..:......................-...---.. ADDITIONAL COMMENTS ---------- --------...................................-....................:...--.----.. .. .. ..0 -` --- - - ............ - ......... .........---......-------------------------------------- .... - -- -------------------- -------------....------..._------------------------ Final Inspection by '-_ - Date... ;... L�� y .............- ....... - ] I SAN JOAQUIN LOCAL HEALTH DISTRICT G E.H.9 1-'6B Rev.5M f� 4 Y r,^ M � ! I 111