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.4o.i , FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i --------------'----- ------- :-------- r Permit No. _7-Z-_ �3 . (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date Issued ___________________ . i Application is hereby made to the San Joaquin Local Health District for a permit to construct,and install the work herein i described. This application is made in compliance with County Ordinance No. 549 and existing Rules 'and Regulations: JOB ADDRESS/LOCATION .----�i- !.--�- /--- --- --- --- ENSUS TRACT -------------------------- Owner's Name14 ----------------- ---------- - Phone -- -j---------� Address -7__ }- ___1 / ----- -- ------ City �----:------------------- - -- -- -- - Contractor's Name ---------- - ------.License #csZ _ __ Phone 4 Installation will serve. Residence)gApartment House[] Commercial:❑Trailer Court ;E]Motel ❑Other ---------------------------;---------------- Number of living units --- Number of bedrooms _ o _____Garbage Grinder -e� - Lot Size __ --____ __�� - Water Supply: Public System and name -E' -----------------------------------------------Private [ Character of soil to a depth of 3 feet: E Sand❑ Silt El Clay 0 Peat❑ Sandy Loam ❑ Clay Loam E] + I 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,) W PACKAGE TREATMENT [ SEPTIC TANK[ ]EX r Sj' - Size------------------------------------------------ Liquid Depth .---_--------------...__-_ Capacity _s_______________ __ Type -------------------- Material---------------- -- No. Compartments _ .4 :Distance to nearest.. Well ---------------------- ------------Foundation - -------------------- Prop. Line ------_---------____-- LEACHING LINT: [ ' No.' of Lines ---------------- _Length of each I'ne____. �_�_.____-- Tota! Length ___- _/..... .; 'D' Box ---F __� Type Filter Materia! ___ . ___.Depth Filter Material ___� f_________________________ C l � Distance to nearest: Well - �_________ Foundation ___ G_..... _-_ Property Line ___,I. ________________ SEEPAGE PIT Depth &;U---------- Diameter Number ------------------ Rock Filled Yes No i❑ Water Table Depth ---------- --- el ��----------------------------Rock Size ----- --- --------_----------- f � r � Distance to nearest: Well -------ta_C/___--------------------Foundation ....Ie' Prop. Line ... ---------------- REPAIR/ADDITION --_____ -----_REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date -------------------•--------------( Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) ------ - ------ .�.t a-- - --------------------------------------------------------I ------------ ----- ----------------------------------------------- - -- -•-------------------------------------------------------------------------------------------------------------------------------------------- # ' (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 Son 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 -------- --- -= ---- ------ - Title ------- (if other than owner) ► y DEPARTMENT USE ONLY APPLICATION ACCEPTED BY r ------------------------------------- ---------- DATE _. '-- Y----------------- ------------------------------------------------------------ BUILDING PERMIT ISSUED _---_----__ -�----~t----__ --- ---- ---- --- --DATE ------ - ADDITIONAL COMM T - - = =/ ------------ ---------------------- -- -- --------------- ------- = -------------------------------------------------------------------- --- ------ ---------------------------- ----------------------- ---------�-- 7- Final Inspection by: ------- -- - ---- -- - ---- ----------- ------------------------------Date ' SAN JO -QUIN LOCAL HEALTH DISTRICT- E. H. 9 1-'b8 Rev. 5M ;