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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �d �S --- 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 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/LOC T10N/04911-C J,----- -- -------------------------------------CENSUS TRACT -------- Owner's Name ---- ----- --- - Phone _ - I Address -------10- ---i7- ----=- City --------------- -------------- yp Contractor's Name:: __ �� :License # lsfr _ .2� Phone � ,- Installation will serve: Resi ence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other ------------------------------------------ Number of living units:------- Number of bedrooms _______Garbage Grinder __._ Lot Size ____________________ Water Supply: Public System and name _____ __ -- PP YY -------------- --------------------------------- ---------------------------------------------------Private Character of soil to a depth of 3 feet. Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan e Adobe ❑ Fill Material ___________ If yes,type ___________________________ (PI"ot 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 {gyp SEPTIC TANK[ ] Size____________ '10___x'________----------- Liquid Depth Y--------------------- iz� Capacity __(-Sae.#�Type r Material_____�_�No. Compartments --- --/----------le O r Distance to nearest: Well S. Foundation ____,f- '__________ Prop. Line ___ ___________ LEACHING LINE [�If No. of Lines .___- ------------- Length of each line------- Vd>............... Total Length - 'D' Box ._ _ Type Filter Material _.__S__R°"�_Depth Filter Material ------/f_-______________________________ Distance to nearest: Well "s°-- ______.__ Foundation ---------/_6 Property Line -.�__________________ r �r SEEPAGE PIT [ ] Depth _._, - ------- Diameter ____ _____ Number --------- ________________ Rock Filled Yes No 0 "Water Table Depth ----------------- ----------------------Rock Size x 3/ -------- - re Distance to nearest: Well _ �' -�__________________Foundation ----- ____ Prop. Line __X____-__---- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank {Specify Requirements] --------------------- --------------------------------------------- ----------------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------- ----------------------------------------------------------- ---- --- ---------- ----------------------------------------------------- ----- -- ------------------ ---------- -------------------------- `' �i'�-� (Dsting&drequired 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 I as to be me subject Workman'�s7 Com�pensati n laws of California." Signed -- - `d �:��..�_ -------------- Owner c ---- Title --------------------------- (If other than owner] FOR DEPARTMENT USE ONLY IV a } APPLICATION ACCEPTED BY --- - - -- --- - ---- -------------------------------------------------------------- DATE _ `deo--r6-------------------- BUILDINGPERMIT ISSUED ------"----------------------------------------=------------------------------------------------ --------DATE ------ - ------------ --------------- ADDITIONALCOMMENTS --------- ---------------------------------------------- ---------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- _--------- -- -- -------------------------------------------------------------------------------------- " --------- Final Inspection by: ------------------------ ----.Date - � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M