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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. <------ This permit Expires Year From Date Issued Date Issued �"�_z 73 --• Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application ismadein compliance with County rdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO AT ON .-_/ _5_4V----- __ _ - ACT - ---- - ---- CENSUS TR Owner's Name ' ---- Phone ----------- Address -__ _la..__34'? , ----------- -- ---- -- -- -- ------------. City ----- - - -------- --------- ----- Contractor's Name _ _ h-( License # Phone Installation will serve: Reside ce ❑Apartment H �Lj mmercial Trailer Court ',❑ Motel ❑Other ___ ----- Number of living units------------- Number of bedrooms ------------Garbage rinder _. -------- Lot Size ----------------------- ------------ ater Supply: Public System and name --__-_--_-__-_- -_-__-------------------- ------------ ------------.-----------•---- - --- ---Private [� ---------------- - Character of soil to a depth of 3 feet: Sand' Silt ElClay F1 Peat E] Sandy Loom I 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,( PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size___________________----------------------------------- ------------_ Liquid Depth __-_--.---_.------___ 6J - Capacity -------------------- Type -------------------- Material Distance to nearest: WNo. Compartments -- aQ --------- •-------- ell ------------------------- ---------Foundation ---------------------- Prop. Line ----------_----_--- LEACHING ---_-----_•-- ,_--•_LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length ---------------- ---------•-- V 'D' Box ------------ Type Filter Material ___________________Depth Filter Material ----------------------------------- Distance _-__-----__-_ _Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------. Number ---------------------------- Rock Filled Yes ❑ No .0 Water Table Depth ------------------------- ---------------.Rock Size Distance to nearest: Well -------------------------------------- -Foundation -------------------- Prop. Line -------_------------- REPAIR/ADDITION(Prev. Sanitation Permit s# ------------------------- ------------ Date --------------------.-_-_--_--_-_-] Septic Tank (Specify Requirements) -.--_ ---_----_- --i- ---------- --------------------•------ . � Disposal Field (Specify Requireme ts) ----CQ ~_ ` - (r - '- --- -----------�-p --- - _ - -- --------------------------- ------------------------- ------- (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 San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome 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 - - ------------------ -- --- - --- BY -- - ( ------ ------ Owner ------ ------ TitlehI other than owner) FOREPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- -- ----------- DATE --------------------------------------------------- ---------------------------- DING PERMIT ISSUED ---------- -------------- --------------DATE ---- ---------------------- ---------- ------------------------------------------------------------ COMMENTS ---------------------------------------- - ---------- ------------ ---------------------------------------------------------- -- -------- --- ------------------- ---------------------•----------------- Fina Inspection by: _ _-____ - ------------------------- ---------------------------------- - Date ---- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M ��