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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------ ------------=------------------------ ------- ' (Complete in Triplicate) ------ ----------------------------------------- ------- ez 7/ , This Permit Expires 1 Year From Date issued Date Issued ____ ___ ____.. II 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 unty Ord'na a No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO - -- --- --- -----l.� CENSUS TRACT ------------_____-__. - ---- 4 -----Phone ------------ ----- Owner's Name -- Y City-- - --------------------------------------- --•------ Address --------1 r Contractor's Name ._-- _ --- Dom.JI _.License # _�` Phone --------------------------•--- Installation will serve: Residence Apartmept,House,❑ Commerci 1 ❑Trailer Court ;❑ Motel ❑Other --------- 7-- --`-`"�� Number of living units:-_____ ____ Number of bedrooms 4c;Z------Garbage Grinder ------------ Lot Size -- - ' I _}____---_Private Water Supply: Public System andiname - € - Character of soil to a depth of 3 feet: Sand I❑ F1Silt Clay ❑ Peat ❑ Sandy Loom Clay Loam.E] i Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ------ ------------------- (Plot plan, showing size of lot, location of system in rely 1 tion #o iwells, buildings, etc. must be placed,on reverse side.) a . t-. NEW INSTALLATION: (No septic tank or seep a .pit permitted if pubis sewer is available within 200 feetJ ./ PACKAGE TREATMENT [ ] SEPTIC TANK''{ Size __, _____ _ _-- Liquid Depth __ -_________________ 1 i Capacity� __ ---- Type Material__c4d7--�-__ No. Compartments --- .-=---- �i stance. to nea st: Well ----------Ja------------------Foundation ----- Prop. Line --- LEACHING LINE [ o. of Lines ------- ------------- Length of each line------- _ ------- Total Length :_/ _f2_____-.--------- 'D"Box .,__----__._ Type Filter Material _____�__�---Depth Filter Material ___ _ _________________j____.----._-_.-- a , i S ance,to nearest: Well _____I- --___-___ Foundation _----��--______ Property Line ___________ _ i ---------- Dist or SEEPAGE PIT [ Depth Diameter "J_�.- ---- Number ---- l Rock Filled Yes No i❑ J �r i r Rock Size Water Table Depth ------------ �------------ ---- ------- �-- i Distancelto nearest: Well ____________ _�Q_+________________FOUndatlOn _____.j_D_�_._--_ Prop. Line -- X.............. i REPAIR./ADDITION(Prev. Sanitation Permit# -•------------------------------------------------------------ Date ---------------------------------- 11 ------------ Septic Tank (Specify Requirements) ----- - --------- ----- ------------ -----------`------—-------------- Disposal Field,(Specify Requirements) ----------- ---- -------------------- ---------------------------=----------------------------- -- __ certify that I have re ared this�appli anon and that th---------- --------------------------------------------- ------------------ ---------------- - ' fDrow•existin and required addition on reverse side) > I hereby'c y p ps a work will be done in accordance with San Joaquin ECounty Ordinances, State Laws, and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- sedvgents signature.certifies the following: I "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 Workmari's pensation laws of ColiFornia." t Signed --------------------- ----------------- ------ Owner { By -------------- -I -------- Titl ---- ------------------ ---------------- - - - -------------- ------------------------ -- (If other than owner) FOR DEPARTMENT USE ONLY 4 I _ APPLICATION ACCEPTED BY ( .Lr ------------------------------------------------ DATE _ BUILDING PERMIT ISSUED -- ------------------- --------------DATE ------------------------------------------ f ADDITIONAL COMMENTS ----------t--------------- ----------------- -------------------- ----------- ----- --------------- ------------=--------------------------- -------------- - -------------------------- ----------------------------- --- --- --------------------------------------------------------------------------- ------ i ------------ = i . - ------- - --------------------- --- Final Inspection b -- ------- --- - - -- ----------------- ------------------Date -� -- - ---- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M