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f FOUR OFFICE USE: _ I— "`- _---------- -------- ---------- APPLICATION FOR SANITATION PERMIT " (Complete in Triplicate) Permit No. 7e:-_ r -- --------------- ------------ This Permit Expires ] Year From Date Issued a� ------� - Date issued --------------`--� . { 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 N 549 and existing Rules and Regulations: r: o. 1f. JOB ADDRESSAOCA- -T-ION ---� Jj-u---0-� _ Owner's Name � ---�-�--D46 y-�� - / ------ - ----CENSUS TRACT -------------- - •------- - --------- Phone._ . '3_-2,fAddress ---- - f --- ----- -------. City Contractor's Name ------ ------------------License # ------------------------ Phone Installation will serve: Residence ❑Apartment House❑ Commercial:❑Trailer Court ;❑ Motel 0 Other g 'C9 o ' Number of living units:---- ------ Number of bedrooms ----------.-Garba a Grinder ___-- Lot Size -_--_-_.--__.-_ - Water Supply: Public System and name -__--- --------- - ----------------- ------•- ❑ ❑ ---------------------------- ----- - - Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay - Private i ❑ 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { SEPTIC TANK I ] Size---------------------- - ------- -------- - - Liquid Depth ------ ----------•- apacitY -------------------- Type ---'---------------- Material------------- ---- o. Compartments ------ ---- Distance to nearest: Well --- --------------------------------Foundation'_ --- ---------------- Prop. Line :-------- LEACH-ING LINE -- [ ] No. of Lines ------------------------ Length of each line------------------- - ` --- Total Length ------•------------------•--._ k 'D' Box .---------- Type Filter aterial --------------------Depth Filter aterial --------------- _- Distance to!nearest: Well:-- --------------- Foundation ------------ - ---------- Property Line PIT ----------------- SEEPAGE ••-- -- f l Depth ------- ------------ Diam er ---------------- Number---------------- ---------- Rock Filled Yes ❑ No ip Water Table Depth ---------- -- --- f - -------------•------ ----------Rack Size -- ---------------------------- Distance ------------•------------ -Distance to nearest: Well - ------ { ------- -------- Foundation -------------------- Prop. Line -------• REP ---------•---- ----------------- AIR. ADDITION(Prev. Sanitation Permit# ------- _ Date ---- ---------------- Septic Tank (Specify Requirements) ----_---_---_---- Disposal Field (Specify Requirem ------------- •. --------•-------- •------------------- ents) ----------------- ---- --- ---------------------------- ---------------- �r - -- -------1 -------------------------- ---------------------------- _ - ----------------------- --- (Draw existing and required addition on reverse side) -------------------------- 1 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: ."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 became s ct to Wok Compensation laws of California." Signed ---- ---------- ----- --- ---- -- ---- -------------------------------------------- - ------- -------- -------- --------- ------ Owner - - -- - -- -- ---- ----------- By title ---------------- ----- - Ilf other than owner) ----- ------- ------------------------------ FOR -- --------- --------FOR EPARTMENT USE ONLY APPLICATION ACCEPTED 'B --- -- --- -- - - ----------------------------------- -------------------------- BUILDING PERMIT ISSUED -------------------------------------------- - DATE _--- -- --=-, _-�/_ ----------------- - ------------DATE ----------------------- -------------- ------------------------- COMMENTS - --------- ------ - --- -=----- -------- --------- ----------------- -------------------- ---------- -------------------- -------------------------------------------------- Final Inspection b p y: _ - - - ----------------------- ----- - ------------- --------- --- --------- -------- -----------------Date -.7_��--'��..- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M