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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 --------------------------- -------_-----_--------------_ 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/L ATION . _ __�+�.�-- .------ -- - &>'�� o ----- -- - CENSUS TRACT -------------------------- Owner's Name --- -------------------------------------- ----------- Phone Address ` City Contractor's Name '.. / it-----X_-_... - ----License # I J Y_`Phone ------------------ ---------- t � Installation will serve: Residence Apartment House-F] Commercial :❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units;----- ____ Number of bedrooms _____Garbage Grinder ------------- Lot Size ____________________________________________ 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 ❑ Adobe ❑ Fill.Material_____________ If yes,type ______________________----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mp st be placed on reverse side.) NEW INSTALLATION (No septic tank or p a pit permitted if public seyver is available within 200 feet,) p PACKAGE TREATMENT [ SEPTIC TANK'seep . .) Siz e1V/s __X--l- -a 5_______________ Liquid Depth Capacity "P-66- ._ e-7-0-� TypeMaterial_K-rl ___t-_ No. Compartments �_____ _____ ___Distance to Weare Well ____----------Foundation ------/RC2_-�__---_- Prop. Line __�-, ___-_- LEACHING LINE [�No. of Lines -_----5------------- Length of each line-----F®---------------- Total Length __.._________-- 'D' Box __ __-__- Type-Filter-MaterialDepth Filter Material -:1- -----------________________________ s11 Distance to nearest: Well _____S ---------- Foundation -----i_-a:+__-�__._-__ Property Line ________________________ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------- '------ ---------------------Rock Size --------------------- --------- Distance to nearest: Well ----------- ----------------------------Foundation -------------------- Prop. Line -----. ------------- REPAIR./ADDITION(Prev. Sanitation Permit# __________________ y--------------------- Date _-____-______--______________.---) Septic Tank (Specify Requirements) _"'-------- -------------------------------------------•---------------------------- -- Disposal Field (Specify Requirements) __;.-_____________ �,• ' _ _________________________________________________________________________.._--_-_________________ 1 { I ------------------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 San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following- "11 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 subje7tJ orkman's Compens n laws of California." Signed ------------------- ---------- - ------------------- wner - By --------------------------- ---',Title ---- =• {If othowner; FOR DEPARTMENTUSE ONLY APPLICATION ACCEPTED BY : - ------ ---------------------------_--- ---------------------. DATE ' ----------------- BUILDING PERMIT ISSUED ------ ---------- ----------- ---------------------------- -------------------- DATE ADDITIONALCOMMENTS ----------------------------------- - ------ ---------------------------- --------- ----------------------------------------------------- ------ ----------- ----------------------------- ------------ ------------------------------------------ --- ----------------------------------- ------------------------------------------------------------------------ 14 _________ ----------- _____________________________________ ___ __-____ -__________________________-_--_______-_______-_____ ________-___-_--________ ___�__ _ ` _ r -___--_____- Final Inspection by. x- - Date ,< SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M.