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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - -------- ---------- ----------------------------- �� `} (Complete in Triplicate) Permit No. ___ ______________ _____ 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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION -------- _ .�-----_/ Lel __- -----------------------CENSUS TRACT ------_------------------- ----- ----------------------- I!� Owner's Name �_�.------ --- ------------------------------- - ---- - -- Phone ------------------------------ Address ------- - ----- City Contractor's Name ...... -�--- License # Phone Installation will serve: ResidenceApartment House E] Commercial ❑Trailer Court ',❑ Motel ❑Other -------------------------------------- Number of living units------ _----- Number of bedrooms ___'�------Garbage Grinder ------------ Lot Size ---------------__________________________ :1 - Water Supply: Public System and name ----------------- --------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt o 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.) t' NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) h 111 PACKAGE TREATMENT [CSEPI-C TANK'[ I Size ._______________________ _ qDepth ap - =- -----=---- - -- -_- - _ Distance to] nearest: Well ------------------------------------Foundation ----------s----------_ Prop. Line ---------------------- LEACHING HNE7'[w1, No. of Lines ------------------------ Length of each fine---------------------------- Total Length ,__________---__--_--___-_-__ t 'D' Box ---- Type Filter Material --------------------Depth Fi:Iter�Matenal ------- - - - --.---------._...----.__-- Distance to nearest: Well-!7_�,-----------Foundation -------�_____---_--_# Property Line ________________________ 5EEPAI1'` LI'] Depth ----- -------------- Dibme�e�-:_---------- Numb er-,--------.---------- -----IRock Filled Yes ❑ No i0Water Table Depth ----<1------------- ------------------ Rock Size,:------ -- - ------- -------- Distance to nearest: Wef,l -----------------------------------------Foundation -------------------- Prop. Line ____._____..__..---_ ' Date ----------------------- t REPAI R/ADDITI�IN{Prey. 5anitation;Permit# ________.__*____________________„R_--- _________} Septic Tank (Specify I2equiremenfs) --- f? -- = ----------------- --------------------------- quiremerifs) ----------------- A�f2equirements} -___ ___ `__ """ _____D ___:l't't-"r _ ________ t _'_ - - ., -r '� lofaw existi and required addition on reverse side) r I herebycertify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations o,fith,e.-San Joaquin Local Health District:j;aome owner or,licen- %( sed agent's 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 Eas to become subject to Workman's Compensation laws of California." ��`^ Signed "oter j ------ ---- _. - Owner J By ---- -------- - t _ ---------------------------------- Title --- - ------------------------------------------- owner) FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY ------------------------------------- -------------------- --------- DATE --7 --------------------- BUILDING PERMIT ISSUED ------------- DATE ------------------------------------------- ADDITIONAL COMMENTS -------�� ----- ------ -��-_j-��---- �. 0 ------------------ ------------------------------ ------------------------------------ -------- ----------------- ----------------------------- ------•---------------- ----- ------- --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- - ---------- ---- -- Final Inspection by: --- `�" ------'-- ------- ---- -------.Date -- ---fir`- -- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT # E. H.9. 1-'6$ Rev, 5M k I