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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------- ---- Permit No. cf' = -------------------- (Complete in Triplicate) - ----------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ------- -- -- _ -------------------------- ---- pas- Application is hereby made tb 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 Ordnance No. 549 and existing Rules and Regulations: 40 jI JOB ADDRESS/LO ATION ___- ��- ----------- --,---- --------- .CENSUS TRACT ---------------------• -- Owner's Name - ..mac- -- ---- - = ---- ---------Phone ------------------------------------ ------------------- ----------------------------------- n Address ---------- � --- r 10 --- _ ' -- -- itY k , Contractor's Name . - -:-��_. +.License # /,FL _ Phone Installation will serve: Residence [4 Apartment House-❑ Commercial :❑Trailer Court i❑ Motel ❑ Other---------------------------------------------- Number of living units:-----1------ Number of bedrooms ___y___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. must be placed on reverse side.) �' 1 NEW INSTALLATION4" {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT CapatE�TIC TANK![ Type --- ___----Size------------------------------------------------Material- _________________ No. CompaDments--------._____._._______h r [ 7 [ ] Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----------..------ LEACHING LINE [ ] No. of lines ________________________ Length of each line.-------------------- Total Length -------- 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ------------------- F 1 Distance to nearest: Well _________________ ---- Foundation ------------------------ 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# __------ --------------- ------ Date _____________ _____________-__) Septic Tank (Specify Requirements) ------------------------- --------------------------------- ---------------------------_ � Disposal Field (Specify Requirements) ---------------------------•-----------------------------------------------------------------------------------------I--------------- i -------- --- -------- � f- ------ E .��' - ---- -- --------------- (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'-� i as to become subject to Workman's Compensation laws of California.' Signed --- ----------------------------------------- -------- Owner BY +_- .------------------ Title __. "�� (If other than owner[ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -.__._ __ _ __ _ _ _ __ __ ----------------------------------------------------------- DATE r ------------------ BUILDINGPERMIT ISSUED ------------------------------------------- ------------------------------ -----=----------- --DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------------- ---------------------------- ---- -------- --------------------------- ---- ----------------------------------------------------------- ---------------------------------------------------------------------------- -------------------------------------- -- - � ------- --- Final Inspection by: _.___f- Date Mrd_" _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M