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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT + -------------------------------------------------- ----- (Complete in Triplicate) Permit',No. --7�--ZS - j ----------------------------------- Date Issued --7=�-7=--7!' This Permit Expires 1 Year From Date Issued ------------------------------------------- Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATI .-5 -.---��--,- - ------------------------------- --.CENSUS TRACT -`r--q-(------------- Owner's Name ------ ------ ----- -------------- ------ - ----- one ------- Cit Address ------ Y Contractor's Name -.License #�dr3y Phone Installation will serve: Residen e 5M Apartment-House❑ Commercial ❑Trailer Court !,❑ Motel ❑ Other ------------------------------------------ Number of living units:_---- ------ Number of bedrooms ---------.--Garbage Grinder ------------ Lot Size --------- ----- ------ ------- ---------Supply: Public System and name ------------------ -------------- =------ Private" Character of soil to a depth of 3 feet: Sand'❑ Silt[] -Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam 0 Hardpan Adobe f7j Fill Material ------------ If yes, type ----------_---------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed' on reverse side.) S NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) SEPTIC TANK Size----------- ----------------- ------------ Liquid Depth --------------------. PACKAGE TREATMENT [ ] ( ] � Ca acifi - Type -------------------- Material---------------------- No. Compartments ------•--------....--- p Y ------------ --- Yp Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .-_---_--------------- [ -------- Len --------------------De Depth Filter Material ----- �----: --------------------------- LEACHING LINE ] No. of Lines ------------- Length of each line.---_-_---------.---_ Total Length', D' Box ---- Type Filter Material p "' Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line ------- ---------------- SEEPAGE PIT [ ] Depth -- Diameter ---------------- Number Rock Filled Yes ❑ - - No i❑ ------------------ WafterTable Depth ---------------------------------------=--------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -.-------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- -------------- pate ----------------------------------) Septic Tank (Specify Requirements) -------------------------------------------------------------------------------•----------- ----------------------------- Disposal Field (Specify Requirements) -- ------------ `- 1 z ------- -------------- --- --- _ - ----------------------------------'--- ------------------------ _ ------------------- - �2 e� - - ----- - --- ------------------------------------ -------=------------------------------- S raw 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: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------------------------------------------- ----------------------. - Owners p_ `- Title __ccr". ------------ BY (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ---------- -- -- --------- -------------------------------------------------------- -------- DATE -�=- -----/ r .. DATE BUILDING PERMIT ISSUED ------------------- --------- ------------------------------- ADDITIONAL COMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------j----- - ----------------------------------------------------------------------------------------------------------- - �,C ,: ► ------------------- ---------- Final Inspection by: - - ----------- ------------------------ ------.Dat SAN JOAQUIN LOCAL HEALTH DISTRICT ` F H 9 1-'6R Rev. 5M