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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------- m Permit No. _ 9_- s�__ '� (Complete in Triplicate) I This Permit Expires 1 Year From Date Issued Date Issued .4- 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 ,Z �,-,�-- -------- -------------.-.CENSUS TRACT ---- ----------- + y- / Owner's Name ------ # /r71�1_ •�#'-- --------------- - ----- Phone Address - i- ------�------- �}_ t!}4-- -----. City --`-- -077'` ------------------------------------- -------- ------ Contractor's Name --- (rt l `C - r -----------------------------License 1 _ Phone !3 _=C Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court 1E] Motel ❑ Other ------------------------------------------- Number of living units_____________ Number of bedrooms .3--------Garbage Grinder ------------ Lot Size - - ---- Water Supply: Public System and name.---------------------------------•----------------------------------------------------------------------- -P Kvate Character of soil to a depth of 3 feet:,, .Sand'F Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ , 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.) �1 NEW INSTALLATION: (No septic flank or seepage pit permitted if public sewer is available within 200 feet,] 01 i INPACKAGE TREATMENT f ] SEPTIC TANK'[ ] 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 ------.-------------------_ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------I-----------------••-------------- Distance to 'nearest: Well ________________________ Foundation ------------------------ Property Line_ -___:_________. ------ _ SEEPAGE PIT [ ] Depth ------- ------------- Diameter ________________ Number -----------.---------------- Rock Filled Yes '❑ No i❑ Water Table Depth --------------------------------------------------Rock_Size -------------------------•----•- .. l `�. Distance to nearest: Well --------- -------------------________-Foundation --------------------. Prop. Line ----------••----•----- REPAIR/ADDITION(Prev. Sanitation Permit t# -------------------------------------------- Date _____-_____________.___._________ Septic Tank [Specify Requirements, ---- �..................... / -...... 4w- ----- - -------------------------- Disposal Field (Specify Requirements) , ..: = -- ------ --------------- _ ------------------- -_ --__;_. -- --- - - - - - - -- --- - (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done"ieciccordance 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 oflthe work for which this permit is issued, I shall not employ any person in such manner as to become subje to Wor an's Compensation laws of California." i Signed ------ -- ------ - -- ---- ----------------- ------------------- Owner C " BY - -�--------- Title (If o#her than owner) _ # FOR DEPARTMENT USE ONLY �J APPLICATION ACCEPTED BY ----- z- ------ -------------------------- ------------- -------------- --------- ------'DATE------------------- BUILDING PERMIT ISSUED - -------------------------------------------- - DATE ADDITIONALCOMMENTS -- ---'----------- ------ -- ------------------------------------ -- ---------------=----=------------------------- --------------------------- ----------- Final Inspectio ,Q---- ----- - - -- --- ----------------------------- ---------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M