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FOR OFFICE USE: - - APPLICATION FOR SANITATION PERMIT .r , Permit No. -7�=--s (Complete in Triplicate) ------_--------------------------_--------------- This Permit Expires 1 Year From Date Issued Date Issued i 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/LO TION/----------------------- ---------------------------------------------------Jl�1._ t CL -------------------------------------------------- ----CENSUS TRACT -- ------ Owner's Name __ J. �! -------Z? /?�_,-c�/------------------- -----------Phone ---------------------------------- Address ------ " / L i.1.v---------------------------------------- City/�F —��---------------- --------------••--•-- � j Contractor's Name ------- -- .---C_"_! �_ j,l ,C ------------------------------License # Y.?"l_-r____ Phone 1__3__-- - - -_ Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units:--------C__ Number of bedrooms _ __Garbage Grinder ------------ Lot Size ______________________________.___-__----- Water Supply: Public System and name ---------------------------------•-----------------------------------------------------------------------------Private ❑ I Character of soil to a depth of 3 feet: Sand'® Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe.0 Fill Material ------------ If yes, type ---------------------------- T (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`[ ] Size________ ______________________ _ ----------- Liquid Depth ________________________- Ca acit __ Type _________________ aterial_________ _ ___ No. Compartments ..................... Distance to nearest: Well ____________________ ______________Fou dation ---------------------- Prop. Line ---------------.-----I LEACHING LINE ( ] No. of Lines ________________________ Length each line -------------------------- Total Length ------------ ................ 'D' Box ------------ Type Filter Materia ______________ __ __Depth Filter----------- Materi ro a - Distance to nearest: Well ____________ __ _______ Fou dation _____.__.__._ Property Line ------- --------------- SEEPAGE PIT Depth Diameter ________________ umber ---------------------------- Rock Filled Yes No Water Table Depth ------------- -------------------- -------------Rock Size --------------- ---------------- J� Distance to nearest: Well -- -------------------- ----------------Foundation --------------------- Prop. Line ......-............... G REPAIR/ADDITION(Prev. Sanitation Permit# ______ ____________________ ________________ Date -----------------------.__________} SepticTank (Specify Requirements) ---------------- ------------------ -------------------------------------------------------------------------_--------------------------- Dispos I 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 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 become subject to Workman's Compenspti.on laws of California." Signed --- - - ---------- Owner------ By ----------- ) � Title ---- ----------------- - ------ ---- ---- ------ ----------------- ------------------ (If other than i FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------f---`--R--V-------------------------- ----------------------------- ------------------ DATE ------ BUILDING PERMIT ISSUED --------- ------------- ------------------------------------------ ---------------------DATE -----------------------------X-------. ADDITIONALCOMMENTS ------------------------------------- -------------------------------------------------------------------------------------------=--------------------------- -- - -------- -- - ---------------------------------------------------- ---------------------------------------------------------------------- ---------- ---------------- ----- -- ------- Final Inspection by: ---- -- ----�F-f.---O'--------• -Date ------ ----- ------------------------------- - -----;-•------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M � j