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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- -- -------------------- --------- I�.-- (Complete in Triplicate) Permit No. f Date Issued --_---- .1 -----------------------------------I---------- This Permit Expires 1 Year From Date Issued 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 :. - --- �h - 5 r ��--- ---------------------CENSUS TRACT --------------•----------- Owner's Name = .Q-'V !�' ---------- e�� -------- - ------- ---Phone -- ---- �' 1 f � ��-------- --- -� - ---------------- Address `�' � �---fi--�:/2�-/�?_?G�l�,�-----------------------City � - - ---------------------- Contractor's Name -��------------------ -=--------License # y - --- Phone Installation will serve: Residence �Apartment House Commercial ❑Trailer Court 'Eli Motel F-1 Other .•------------------------------------------ Number of living units:......y----- Number of bedrooms --- Garbage Grinder ------------ Lot Size -.----__----____------------------------ Il. ------Private Water Supply: Public System and name ---------------------- ----------•------------------- ------------------------------------ Character of soil to a depthlfof 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. must be placed on reverse side.) i NEW INSTALLATION: (Nt septic tank or seepage pit permitted if public sewer is available within 200 feet,) f PACKAGE TREATMENT { ] SEPTIC TANK [ } /ae ze-------- ---------------- --------------------- Liquid Depth ----------.--------------- it -.-- No. Com I Capacity --- ------------ Type - - ------ aterial--- --- ----- - _partments --------------..._..-- , Distance to nearest: Well ------ -- ---------------- oundation ------------_----- Prop. Line .---------------.----- N IM � LEACHING LINE [ ] No. of Lines ------------------------ Leof each I• e---------------------------- Total Length -----.----.----------------6 it 'D Box ------ ----- Type Filter Ma ---------- --------Depth Filter Material -------------------------------------------- i Distance to nearest: Well ------ - ------- oundation .--_----------- ------ Property Line, ------------_-----.:---_11� SEEPAGE PIT [ ] Depth _.--__-___-.--__-- Diom er --- ---- Number ---------------------------- Rock Filled Yes ❑ No i❑ - i Water Table DepthRock Size IM' Distance to nearest: Well ---------- -------------- ------Foundation -------------------- Prop. Line --------__....._-----iREPAIR/ADDITION(Prev. Sanitation Permit# ----------------- ------------------ Date --_--_----------_---.___-__------} IN SepticTank (Specify Requirements) ----------------------------------------------------- ------------------------ --------- ------------ ------•.<----------------------------- ------------ ecif Pl Field Disposal S if m ------•------•----- -- ---- -- ------------- _ -------------------------- P Y Re q uire_ens) --/ v' - ' = - --- - Zf il 11 (Draw existing and required addition on reverse side) I hereby certify that 1 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 Iicen- I sed agents signature certifies the following: ` "I certify that in the perfo�hmance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to W`ork n's Compensation laws of California." Signed - -I. -- r _ Owner iM - BY ----- --- ' :'--- ------ -------------------------- Title ..---------------- ---------------------------------------------------- -• -----------. (If other tha';' owner) FOR DEPARTMENT USE ONLY -`0-7 APPLICATION ACCEPTED IfBy ---------------------- -- - --- ------- ----- - --- =- -- --- ------ - -------------------- - ---------- DATE ---- BUILDINGPERMIT ISSUED --------------------------- ------------ ------- ---- ------------ ----- ----- --------------DATE -----------------•------------------------- ADDITIONALCOMMENTB�----------------------------------------- -------------------------------------------------------------------------------------=--------_---------------- ---------------------------------'--------- ---------------- - - ------------ - -------------------- ---------------------------------------------------- ------------------------------ ------------------------ -------- ---------------- --------------------------------------------------------------------- - ------------ ---------------- -----------i Inspection by. �� ------ - -------.Date - -- 7 -------------------- ------------------------------ `r� ' SAN JOAQUIN LOCAL HEALTH D TRICT E. H. 9 1-'b8 Rev. 5M ;F