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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. "--7-Z-.Z-�-� ----------------------------------- -------------------- (Complete in Triplicate) ---------=---------- -- • Date Issued ----------- ------- This Permit Expires 1 Year From Date Issued ---------------------------------------- ---------------- D 2(^r leo If Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and epsting Rulps and Regulations: ! ---CENSUS TRACT ---`-- - -- - -------- ----- JOB ADDRESS/LOCA �P�-------�� -- --.. 10 ----- Phone ------- ------------------------- Owner's Name _ , Address ---3--- ---- City r -------- -- /�d'� Contractor's Name --------- --- -E I� -'--- ----- License # -[ -- �------ Phone ---- ------------------------- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:----I------ Number of bedrooms _""---_"_"-_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 E] 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.)i_1W'�r- p NEW INSTALLATION (No setic tank or seepage pit permitted if public sewer is available within 200 feet,l PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size---------------------------------- ------- Liquid Depth --------------------,- Ca acit ------- Type ---------- ------ Material----------------. ---- �No. Compartments ----------•-- p Y ------- Yp , _ Distance to nearest: Wel! ------------------------------------Foundation----------------------- Prop. Line ---_----------------- LEACHING LINE [ ] No.' of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------- Distance to nearest: Well ------------------------ Foundation -------------------- --. Property Line ---__--------_---------- SEEPAGE PIT [ ] Depth ---------------- Diameter ---------------- Number -----------------: ----- -- Rock Filled ,Yes 0 No..ip WaterTable Depth ------------------------------------ -----------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------...... ----- REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------------------------=--------- Date ---------------------------------- ----------- 1 Septic Tank (Specify Requirements) ------------- -------------------"------------------- �� Disposal Field (Specify' Requirements) -_ -- o - -- - --- =- -- -------- " 144, --- - - - -------- --- --------- ------ -------------------- --------------------- --------- j ------------- --------- --- ------------- --------------------------------------------------------------------------------------------------------- -------------- ------- ------ (Draw existing and required addition on reverse side) ' I hereby that I have prepared this application and that the work will be done in accordance with San Joaquin y 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 as to become subject to Wi rkman's,Co pensati.on laws of California." Signed ------------------ Owner -- --------------------- --------- --------------- -- ---- --- - itie -_ � �--------------------------- (if other than owner) FOR DEPARTMENT USE ONLY p 11 59 APPLICATION ACCEPTED BY ----------------------- DATE -- - -------- - --- ----------------------- BUILDING PERMIT ISSUED --------------- - ------------ -------------DATE ------------------------------------------- ADDITIONAL COMMENTS -- ------------- - ------------------ ------------ ------------ -- --------------------- ---------------------- -- --- -------------------------------- ------------ ----- --- --------- - ---------------- --- -- ----Z------------ --- ---------- Date 7 Final Inspection by: -------- ---------------------- ----- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT F H 9 1-'6B Rev. 5M