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FOR OFFA USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -- I __-------------------- This Permit Expires I 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I JOB ADDRI_SS/LOCATI N -----_ �a _ �.a1 Yy ------------------ ----------------------- --CENSUS TRACT _----------------•-------- Owner's Name 4-h , - Phone ----------- r ;. Address l:r - - Ali-L-° s— City tl ' ►--- ------------- --------------- Contractor's Name -- '' License #1 -- f Phone Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ t rMotel ❑ Other -- ----------------------------------------- Number of living units:________!_ Number of bedrooms ___-Garbage Grinder _4-,4P Lot Size _. d- _ .... , Water Supply: Public System and name --- ----K--- -'--= --------..---------------------------------------------------------------------------Private f ' ! Character of soil to a depth of 3 feet: Sand'❑ •silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [] Hardpan ❑t " "Adobe Fill Material _. if yes, type ---------------------------- r (Plot plan, showing size of lot,''locatibn of system in to:wells, buildings, .etc. must be placed on reverse side.) NEW INSTALLATION.+L;(No septic tank or seepage°pit permifted 'if-rpublic sewer is available within 200 feet,) WPACKAGE TREATMENT [ ] SEPTIC_ WANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- 0 Capacity ---;-A------_- -- Type ------4------ --'- Material---------------- ----- No. Compartments ----------------• ...t_ - . Distance to nearest: Well- ------------------------------------Foundation ---------------------- Prop. Line -----------------_--._ , LEACHING LINE [ ] No. of-lanes---___--'--•---n-j—L•ength-ofreach.line___..________.______-t_ " _ _19n__iR-- ---- Total• Length --------- 'D' '------ •-•=-•-------- 'D' Box ----y----- Type Filter Material --------------------Depth Filter Material --------------------- ----------- s 9 Distance toInearest: Well -----__ dation __.____________________ Property Line __:J________' .._.....,,_ SEEPAGE PIT { ] Depth ____________ Diameter Nu tuber ---- Rock.Filled Yes'❑ No Water: Table Depth _____________ = - - ---------------------= Rock Size ----------------------- ------ Distance to nearest: Wel! __ >_ ------Foundation -------------------- Prop. Line _-----------------_-- r .. i REPAIR/ADDITION(Prev. Sanitation Permit# -------------- -------------____________L Date ----------------------------------I Septic Tank (Specify Requirements) ------- ------------ ---------- �---------------------- Disposal Field (Specify Requireents)_. f -- -- m _- �,]` -- --- - -- 6c1 - ------------------------------ -- -------- ------- - ------- ----- ------------------------------- ----..----fir = ---, (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 Son 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- "I 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 to Workman's Compensation laws of California." Signed ----------- Owner By ----------- ------------------------ Title . -- 1Ir . ' if er than owner} i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYI-• ---Zs ........................ --------- - --------- DATE ...... f-- - BUILDING PERMIT ISSUED ------------- ------------------------------------------------------------ ------=--------------DATE -------------- ADDITIONAL COMMENTS -- --------- ----------------------------- -------------------------- ----------- ------------------------------------ ----------------------------- ----------------------------- ----- ---------------------- ---------------------------------- ---------------- -------- i --------------------- -------- -------------------- --- -- - Final Inspection by: ----- - --------------------------------- -------------- ----------- --------------------Date -------------------- S N -------------------SAN JOAQUIN LOCAL HEALTH DISTRICT E. H."9 1-'b8 Rev. 5M