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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ---- ---------------------------- ----------------- 1 (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 madeiin compliance with County Ordinance No. 549 and existing Rules and Regulations: I ------------CENSUS TRACT -------------------------- JOB ADDRESS/LOC &IN ------ _---- i -----Phone Owner's Name - - ---------- - - ---------------------- ------------------------------- ----------------- -- ----- Address a-�--- " " -- y Cit ---------------------------------------•----•-••--- d ' --- - ------.License # -��FT3_1------ Phone ------------------ ---------- Contractor's Name ----------- t 6 I Installation will serve: Residence [Apartment House Commercial ❑Trailer Court ;❑ „ Motel ❑Other -------------------------------------------- Number of living units:__-l------ Number of bedrooms ---?IIIIIII�arbage Grinder ------------ Lot Size ---------------------------------- Water ----------------- - -------------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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} J PACKAGE TREATMENT [ I SEPTIC TANK"[ ] Size--------------------------------------- Liquid Depth ---------------- --------- Capacity - Type -------------------- Material-------- ------------- No. Compartments ------ ---------- Distance to nearest: Well ------------------------------------Foundation ---------------------- prop. Line ___.------------------ j LEACHING LINE [ ] No, of Lines ------------------------ Length of each line-------- Total Length -----------•----•------• 'D' Box ____-------- Type Filter Material --------------------- Depth filter Materia ------------------------ ----------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ z SEEPAGE PIT [ ] Depth -------------- Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No I❑ Table Depth Rock Size ------------------------- ----- ---------------------------------------- --- --- - D stance to nearest: Well ------------------- - -_-.Foundation -------------------- Prop. Line -----------------_--- rC - ------------ -- 1 --------- Date ----------------------------- REPAIR/ADDITION } (Prev. Sanitation Permit# ____---------------------------- ft --- --- Septic Tank (Specify Requirements) ..---------------------------- _ = _----------- Disposal Feld (Specif Requirements} ___0—--.; -- - -- 4 - Disposal -C--- .......... ----- ---- ---------------------------------------------------------------•--=------------------ --------------------------------- ---------- --- ---- ----------------------------- -------- ---- - (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: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject e'�an man's Compensation laws of California." 4 Signed -_- - --- ----- -- --- ---- ----- ---- Owner , e . t- Title : � (If othewner) __• � - F -�` i FOR DEPARTMENT USE ONLY 1,10!APPLICATION ACCEPTED BY -- - ------- ------------------------------------------ DATE ------ -'�--------------'��----- BUILDING PERMIT ISSUED ------------------------------------------------------- -------------------DATE ------------------------- - ------ -------- ' ADDITIONAL COMMENTS -----------'----------- i -------------------------------- i ------------------ --------- ------------------------------------------------------------ -------------------------------------------- - Dat Date Final Inspection b SAN - ,'� 1 JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M