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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - ------- ------------------- -- Permit No. (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date issued \S- - --- --- ------- -------------------_---------------- 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 ._�k//--- ___ rl ,7, ------------- ------------------------ ----CENSUS TRACT -- S-�l ------------- Owner's Name --- -- ---- -------------------------------- ------- Phone ----------------------------------- p n -AddresslCity; -.License # -lff3k� ------ ----- ----------------- Contractor's Name --""--- -� - - - --- ------ - --- Installation will serve: Residence Apartment House❑ Commercial [—]Trailer Court ;❑ r ' Motel E] Other ------------= -- -------------- Number of living units:-------� Number of bedrooms __c_7_'__"�-.Garbage Grinder __ --------- Lot Size __ 'z` `- �'------ Water Supply: Public System and name ---------------------------------------------------------------------------------------- -----------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam (Clay Loam ❑ Hardpan F❑ 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'[ I Size----------------------------------- ------ Liquid Depth ----------------------- Capacity -------------------- Type -------------------- Material---------------------- .No. Compartments ------•----_- ------- Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line --------------..______ A LEACHING LINE [ ] No. of Lines ------------------------ Length of each line____________________________ Total Length ,.-------__,__ ~ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _.-------------.-----------..--------------- Distance to nearest: Well _______________________ Foundation ------------------------ Property Line _______-_________._____ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C3 WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------........... REPAIR/ADDITION(Prev. Sanitation Permit# ----=----------------------------------- -- Date --------.--------------.----------) SepticTank (Specify Requirements) ---------------- ---------------------------------------------------•--------------• ---------------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------ -------- --------------------- ----------------------------------- r - ` � . -----_ - -------- ----------- -------------------------------------------------- flQ -F----------------------- ----- ------- = (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 --- ------------------ Owner BY r _ Title (If other than owner) FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED BY __. ------------------- - ------------------------- -- -- DATE -------------- BUILDING PERMIT ISSUED ------------------------------------ ------- --------------------------DATE -------------•-------------------------•--- ---------------- ------------ ADDITIONALCOMMENTS ---------------------------------------------------------------------- --------------------------------------------------------- ----------•---------------- Final Inspection by: -------------- Dater ) ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E, H. 9 1-'b8 Rev. 5M