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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------------------------: --------------------- i Permit No.. [Complete in Triplicate] ------------------------------------- ------------------------------------------------ 'This Permit Expires 1 Year From Date Issued Hate Issued t - F � Application is hereby made to the4San 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 existi Rules and Regulations: JOB ADDRESSAOCATION ------- � _ SUS TRACT --------------•----------- ,f Owner's Name -----��f��'C:f----�,07--cc--------------------------------------------- - •------- -- Phone ------------------------------------ --------- --------•------------------------- -- -yam Address ._---- �-" ' City i / / ``''� ------------- ---------•---•-•--••--- i Contractor's Name ------ f,P-'- / r �� J'----------------------4---_--.License ".7,4-9t- Phone 4- I --i Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court Number of living units:---/ Number F-1 Other -----------------------------•--------____-- g --.-_ umber of bedrooms __.-----Garbage Grinder _. Lot Size1A_0__X--off ----------- ' __-_---- . Water Supply. -Public System and name -- ----------------------- ---------Private Character of soil to a depth of 3 feet: San 0 Sift Q Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 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.) F NEW INSTALLATION: (No septic sank or seepage pit permitted if public sewer is-available within 200 feet,) j Capacity IC TANK Size_ � ��__ _ ._- ------ Liquid Depth _ F. PACKAGE TREATMENT SEPT -_-�C-;- :- ---'- - -, . -, q p �,/----.._...---.----- ,. C ] - p p y - _�_ __::__ Type oa4_44s[_ Material j�j'1�/'r'd No. Compartments 2-...__._.- N i Distance to nearest: Well ---e,Za---------------------Foundation,_Aa-__-_-___-___ Prop. Line .,?0-,.___.______ LEACHING LINE No.B x Lin4L-3- � Type Filter Mategial th o�each�p,t`�.Depth 4p�----------------- Total Length ,__�+��................ yp �• -._ De th Filter Material _ ----------------------------------- Distance to nearest: Well -------- Foundation ............ Property Line. A ______________ r r SEEPAGE PET [ ] Depth ; -------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .i❑ Water Table Depth ------------------------------------------------Rock Size ---------------------------- Distance tolnearest; Well -----------------'---------------------Foundation ---------------.--,. Prop. Line ------_--------------- ' REPAIRfADDITION(Prev. Sanitation�Permit# -------------------------------------------- pate -----------------___-----_____) t - SepticTank (Specify Requirements) --------------------------------------------------------------------------- ---------------------------------•.--------------------------- Disposal Field (Specify Requirements) ---- j I -----------------------.------------•----------- ----- ---- --------- ------------------------------------------------------ ---- ------------------------------------- ----- ------------------------------------------------------- --------------------------------------------------- ------------==------------------------------ --- (Draw existing and required addition on reerse 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, a'n'd 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 Compensation laws of California." ! Signed ---------- ---- -------------------------- --- --------------------------------------------Owner BY ------ -- -- ------------------ Title --- -- � -------------------------- ot er than owner) FOR- DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ............. 1' ----------------------------------- -----. DATE - --------- BUILDING PERMIT ISSUED -----------1! -------------------------------------------------------------------------------DATE -------------------------------- 1 ADDITIONALCOMMENTS -------------- ---------------------------------------•- ----------------------------------------- --- -- ------------------------------------------ 3 I f ------------------------------------------'---------------------------------------------------------------------------------------------------------------------- ------ - - - -------------------------`-----------------------------=-'--- - ----------------------------------------- . -------- ---- --------- -- ------------------------------ --- - Final Inspection by: / 'e ----- -Date ------�' g sl SAN JOAQUI,N LOCAL HEALTH DISTRICT r . E. H. 9 1-'6B Rev. 5M