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FOR OFFICE USE: APPLICATION FOIL SANITATION PERMIT permit No- ----------------- ------------ (Complete in Triplicate) � 'Date Issued -- --��-�• --------------------------------------- This Permit Expires 1 Year,From Date issued F ---------------------------- --- permit to construct and install the workhere A lication is hereby made to the San Joaquin Local Health DistOrdi a a p pp • is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: described. Th pp _CENSUS TRACT -------------- ----------- ---------- --------- --- f _._ - JOB ADDRESS/LOCATIO / ----- `..._ Phone �-� Owner's Name f Cit - ------- YY� Y -- - Address -------- ' -- -- -- -- - --. 1 � hone License # Contractor's Name ------ Installation will serve: Residence k artment House,❑ Commercial;[}Trailer Court ',E] Motel QOther ----- --- - ----------------------------- - - Garbage Grinder Lot Size _-"------- - _- Number of living units:_-----1--_ Number of bedrooms -------Private ------------- ------------ Water Supply: Public System an name -------------------------------------- -------------------- - -" -- - Peat❑ Sandy Loam � C1ay Loam.E] Character of soil to a depth of 3 fp. t: Sand Q Silt Q Clay ❑ Hardpan❑ Adobe Q Fill Material ............ if yes,type --------- --------- ---- --- I laced on reverse side.) buildings, etc. must be p r N {plat plan, showing size of lot system in relation to wells, t t 'it ermined if public sewer is available within 200 feet,) NEW IN5TALLATION: (No septic tank or seepage p' ,p � '-�."� - ------------------------------ PACK ------------------ ---- -- ---- Liquid Depth - --- --------------.---- I SEPTIC TANK:[ ] Size \ AGE TREATMENT [ 7 _ _ No. Compartments ---------------------- II .-- Material_"_----- Capacit Type Y ---- ---- - -- --- � --- �-��-- ------Foundafiion - ---- ---------- ---- Prop. Line ---------- Well --- --------=-:------ ► -------------- Distance to nearest: Well Total Length ---- 4 LEACHING LINE [ J No. of Lines ------------------------ Length of e6 -Depth - ----------------- I "Depth Filter Material ----------•---------•--•---"---`""""'------" � D, Box ------------ Type Filter Material - F Line. --------------No- ' # ____-__--- Foundation Property -------------- Distance to-ne Well�':"------- Rock Filled Yes ❑ �. Depth Diameter ---------------- Number ----------------- SEEP E PIT [ t : V Rock Size ----------------- ------ ------ LF Water 'Table Depth -------------- ------------------------=--- f Line ----------- -----•- - R i Distance to nearest: Well _--_------ - ----Foundation -------------------- Prop. i t. ---- ----- ----- -`- Date --------------------------------- REPAIR/ADDITION(Prev. Sanitation Fermi- ----------------------- i Septic Tank [Specify Requirements) "------ Disposal Field [Sp cif Requirem�ts] -- ---_--- -,.a Yred1 t - --------- ------------- ------------------------------------------ a I {Draw existing and re uired addition h rev " " ----------------------------------------------- - tr __-___-" -"__""---------------:-�- ----- ------------ q on reverse side) - -----------------t I hereby certify that I have prepared this application and thata work will be done in accordance with San Joaquin CountOrdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- Y sed agents signature certifies the following: p person in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any as to become subjec to Work'man's Compensation laws of CaliFornia." �1 Own e Signed ---- - Title r V --$ - ---------- � - -- ":_. 1 (!f other than owner) FOR DEPARTMENT USE ONLY DATE _.�.---�._I�y-�'--�------------- I APPLICATION ACCEPTED BY I --- - -- ------------------- ----- DATE ------- ------ -----------=-------- ------- BUILDING PERMIT ISSUED ------------------------------------------------- ----- ----------------------------------- --- -------------- ---------------------------------- --------- ADDITIONAL COMMENTS _-"�------ -- -------------- ----------- -------------------------- ---------- ----------- ------------------------------------------------------ -------------Date -" /4 V1 *-- ------ -------------- ------------------------------ - ----- ------------------------------ Final Inspection --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M