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OFFICE USE: APPLICATION FOR. SANITATION PERMIT _.- Permit No. ---------- - - ---- - I�FoRz, --- -------------------------------------- tt�omp!ete in Triplicate) --- ------------- Date Issued i This Permit Expires 1 Year From Date issue -------------------------------------------- Application is hereby made #o 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 CENSUS TRACT ------ r JOB ADDRESS/LOCATION .-_ s ------- Phone ) = Owner's Name --111 � �1� � n' -�- � ,,�� •-City Address ------- y ----------------- 7�t License # 177-tr< ---- Phone Contractor's Name 4 Installation will serve:` Residence F1Apartment House-F-1 Commercial ❑Trailer Court `❑ Motel ❑Other ------------------------------------------- Garbage Grinder --- Lot Size --�'- _-- .------------------- Number of living units:---- -- Number of bedrooms -- - private ❑ Water Supply. Public System and name ---------------------------------- - Character of soil to a depth of 3 feet: Sand'❑ Silt❑: -Clay,.E] ..Peat❑ Sandy Loam El Clay Loam El ElHardpan ❑ 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.] V l P NEW INSTALLATION: (No septicItank or seepage pit permitted if public sewer is available within 200 feet, PACKAGE.TREATMENT [ ], SEPTIC TANK'[ ] Size------------------------ -L--- ---- Liquid Depth -------------------------- No. Compartments --_------------------ Capacity ------ ------ Type -------------------- Material--------------------I- P V Distance totnearest: Well `-- --------------------------------Foundation ------- - -------------------•_Foundation - ----------- Prop. Line -------------- ------ LEACHING LINE [ ] No. of,Lines ----------- -"---------' Length of each line--------------------=------- T, -- -- Total Length T Depth Filter iMaterial ---------------------------------------•---- f D' Boz.-- --------- TYPe Filter Material -----------•--- P Distance to nearest: Well --._------------------- Foundation --,----------- Property er Line ----------------------- i thDiameterNumber ---------------------------- Rock Filled Yes ❑ No 0i SEEPAGE PIT [ ] P ------------ --- I De ----------- -• ------Rock Size -------------------------------- Water Table Depth --------------------------------- , 1t .Foundation ------------------ Prop. Line ---------------------- Distance to nearest: Well --------------------------------------- _ - Date -- ------•----'-------------------] 4 REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ � 11e------ Septic Tank (Specify Requirements) --------14,019-------� Disposal Field (Specify Requirements) --------------------------- ------------------------------------ --------------------- ----------- ----------------------------------------------------------- -------------------------- i ---- ----------------------------------------------------------- ----------------- (Draw existing and required addition on reverse si e ce I hereby certify that I have prepared this and application ulati Reghat the work will be done in ulations the San Joaquin Local Health D strctnHomeitowner or I cen- h Son Joaquin County Ordinances, State Laws, and RulesdReS 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." Owner Signed -------------------- ---------- - ---------------- - --- y -- ----- " --------------- �/� T tie ------------ - Y (if of than own FOR DEPARTMENT USE ONLY DATE _T-PT/-10-= �"`-------------------- ----- --"`-- ------------------------ APPLICATION ACCEPTED BY s DATE -------------------------------------------- DATE PERMIT ISSUED ------------------------------ ------------------------------ ------------------ ADDITIONAL COMMENTS ------------------------------------------------ ---------------------------------- ------- - ------------- -- ---------- -------------- -----------------------------•--------------------------------------- --------------------- --------------------- ----- - --------------------------------------- --- - Date - Final inspection b ----- -- -- -------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1268 Rev. 5M