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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. Z ------ ----- (Complete in Triplicate Date Issued This Permit Expires l Year From Date Issued Application is hereby made to the Sa 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: 7S ._. . . -------CENSUS TRACT - ---- -------- - -- JOB ADDRESS/LOC/�TI one ------ . �yCYI 1._------• Ph Owner's Name p -. Address ------ --;=-- -U.� -----��---------- --JceApartm -------------------- - ° �„r,�_ t License # - 3---y_ Phone -----•--- Contractor s Name _----- - ---Installation will serve: Resideent House Commerual ❑Trailer Court ;❑ E Motel ❑Other --------------------------------------------- Number of living units:_-.---- _- Number of bedrooms __ _____Garbage Grinder ------.----- tot Size _--- - --- - l --- -----------------------Private Water Supply: Public System and name ------------------------------------ - Character of soil to a depth of 3 feet: Sand'❑ Silt❑.. .Clay ❑ Peat❑ Sandy Loam`, Clay Loam El - r - ,r- } Hardpan [-IAdobe 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.) P seepage pit permitted-if,public sewer is available within 200 feet,) V NEW INSTALLATION: (No septic tank or � Liquid Depth --------------------------- PACKAGE TREATMENT [ SEPTIC TANK-[ I Size----------------------------------- q P Capacity -----------------.__ Type ---------------:---- Material------ -------- --- No. Compartments ------------ ----- +1 =-Foundation ---------------------- Prop. Line .--------•------------ Distance to-nearest: Well ------------- ------------ -►1 ...r ..� w� ---- Total Length -----------•---------------- LEACHING LINE [ ] No. of Lines - ------ Length of each line-------------------- g '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 DepthRock Size -------------------------------- ---------------------------------------- Distance to nearest: Well ----------------------------------------- ------------------- Prop. Line ----------------•--- REPAIRfADDITION(Prev. Sanitatior, Permit# -------------------------------------------- Date --------------------•------ ------1 --•----------------•-•---------- Septic Tank (Specify Requirements) ------- ------------------------------- Disposal Field (Specify Requirements) if �------ x ^`--- s-------- ---------- ------------------------------------------ - ---------- - _ _ ------------------------------ -- --- ----- ---- ---- -- --- - - - ------- ------- (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 - --- -- - . ---"--. --- -- Title - ------ -------------------------------- (If other than owner) F R DEPARTMENT USE ONLY sr APPLICATION ACCEPTED BY -, _- ------- ------------------- DATE .�- --------�---- -------- ------- -- - ------------------- - DATE BUILDING PERMIT ISSUED ----------------------------------------------- ADDITIONALCOMMENTS -------------- --------------------------------------- ---------------" "------------------------------------------------------------"---------------------_---"---""-_____- ---------------- -------- ---- -------------------------------------------------------------------------- - - fi _ 7� ------------ ------------------------------- n Final Inspection bY -- - - --------------------------------------- . Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M