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FOR OFFICE USE: - . APPLICATION FOR SANITATION PERMIT ---- - - - --------------- - - - Permit No. --------------------- (Complete in Triplicate) This Permit Expires 1 Year From bate issued Date Issued -- -------------------------------------- _ _ _-_ - -------- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereir described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION F -:----CENSUS TRACT -------- iPhoneOwner's Name ------- - ------ :-- ------••"---- ------------------- ------ --------- Address ------------ -- ----- ------- -- -- City --- --------- - - Contractor's Name ..-- - --_- ----..License # ,�q - -Phone Installation will serve. R ence ❑ Apa Hent House❑ Commercial ❑Trailer Court Motel ❑ Other -------------------------------------------- Number of living units:___. t_ Number of bedrooms ------------Garbage Grinder -------- --- Lot Size -------------------------------------------- Water ___ _--_________________________________Water Supply: Public System and name --------------------------------------------------- --------------- ----- --Private Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay Peat ❑ Sandy Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes, type ___________________________ i (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,) W i PACKAGE TREATMENT ] ] SEPTIC TANK [ I Size-----------------------------------.------------ Liquid Depth --,----------------•.---•- Capacity - ----------------- Type -------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation --------------I------- Prop. Line ______--___________ - LEACHING LINE; . [ ] No. of Lines ------------------------ Length of each line-m_-----------------__:_,__4_ .Total Length ,_._______...__.____......-- 'D' Box ----------- Type Filter Material _______________ ---- Filter Material ---------'.. - Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ____-----_._____--_----- SEEPAGE PIT [ ] Depth ___.-.____. Diameter ________________ Number ----------------- ---------- Rock Filled Yes ❑ No .0 Water -Table,Depth ---------------------------------------------------Rock Size -----I------------------------ Distance ---:-----------Distance to nearest: Well ----------------------------------------Foundation- -------------------- Prop. 41-ine ------.----------.-•-- REPAIR/ADDITION(Prev. Sanitation Permit# _-_____..___________ ------------ Date ----------- ------ Septic Tank (Specify Requirements) - ------- ------------------------------------ -------------------------'_ --------------------------- ---------------------------- Disposal Field (Specify Requirements) -------- L Jai P - ---- - -----{Draw ---xisting and regvi ad-- d -- - i on a - on-r- ----r e si e- - - - -----------------------------•- e I hereby certify that I have prepared this application and that the work w be done-in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaqu 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 becou ct to Workman's Compensation laws of California." Signed ----- -7than Owner s B ---------------------------- �� ---- --------------------------------- ---------------- Title - �- - (If othown I FOR DEPARTMENT USE ONLY ~7=3----------------- APPLICATION ACCEPTED BY ----------------------------------------------- ---- DATE -f BUILDINGPERMIT ISSUED ----------- ------------------------------------------------------------------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------------------- ---------------------------•------------------------------------------------------------------------------------------------- --------------- --- -------------------------------------------------------------------------------------------------- ------------------------------------------------------ ;a.-..' - ------------------- ---- ----------- `-------- -- -_.------------------------------------------------------------------------ � - --- - --------'-______ Fin al.Inspection by: - -------------•------------------ -- ---------------------------- Date + �' SAN JOAQUIN LOCAL HEALTH DISTRICT /I N i E. H. 9 1 '68 Rev. W '"