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} J FOR OFFICE USE: ; APPLICATION FOR SANITATION PERMIT , --------------------------------------------------------- Permit - --:�� (Complete in Triplicate) This Permit Expires 1 Year Fro bate Issued Date Issued --------------------------------------------------------- ----------- _ -------- -------- ----- _ __ ------------ rt 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 ounty Ordinance No 549 and existing Rules and Regulations. l�l . ------- ---- CENSUS TRACT --------------•----------- JOB ADDRESS/LOC - -------- � Owner's Name -� - ------------- ------:---------- = - --------------------------------- -- - - - ----- - ---- - _ __._ Phone Address �' _ City - - - -- - ---------- -----•-------------------••------------- r .Lieense #J� -- Phone ----------------=------------- Contractor's Name ------ - =�I Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- Number of living units:_->_- --____ Number of bedrooms ___________Garbage Grinder _______---- Lot Size _--_______--------------------------------- Water Supply: Public System and name - - --- ----------- -- -- Private ❑ Character of soil to a depth of 3 feet: Sand' Silt(] Clay ❑ Peat❑ Sandy Loam -❑ Clay-Loom Hardpan ❑ Adobe'❑ Fill Material .___ ------ If yes,type ---------------------------- F (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'[ I Size-------------------- ------------------ ------ Liquid Depth -----------------_ ------ Capacity Type ------- Mafierial---------------------- No. Compartments -----------•---------- r I a Distance to nearest: Well ------------------------------------Foundation ---------- Prop. Line ---------- ------- LEACHING -----LEACHING LINE ['j No. of Lines ------------------------ Length of each line---------------------.------ Total Length ............................ �+ D' Box ._•---_-__-- .Type Filter Material ---------_--=--------Depth Filter Material ---------------- --- ----------------•-•---- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line. ______--______-_--.:-_-- SEEPAGE PIT Depth __ Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No Water Table Depth ------------------------------------------------Rock Size ------------------------- - f ' r d"i"stance to nearest: Well -_________c______------------------__Foundation ----------------- __ Prop. Line ....___._______......- � REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------11 Septic Tank (Specify Requirements) ----- ----------------------- --------------- ------•----------:-------- -------- -------------- ---------- Disposal Field (Specif Requirements) ----- ` --- 01 ez_ r f; -------------- - --- --- ------------------------------------------------------------------------------------------------ (Draw existing and:required addition on reverse side)- icen Thereby certify that I'hcve prepared this application'and-that the work-will-be,don e-iin accordance with•°Son,Joaquin- County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or l icen sed agents signature certifies the following: ; "I i;ertify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as to become subject to rkman's Compensati a f California." _ s .� - ( O wner Signed - - ----------- ----- -- ----- - - `aTitle ., --------- ------ --- --- . .�� BY (If other than owner) FOR DEPARTMENT USE NLY r� APPLICATION ACCEPTED BY --- ------ --~---------------------- DATE -G= ��'1 -- BUILDINGPERMIT ISSUED --------- -----------=------- -----------------------------------------DATE _------------------------------------•--- -------------------------------- ---------------------------------- ADDITIONAL COMMENTS -------------------- ' ------------=---------------------------------- ---- - -- } a. --------- --------- ------------------------------ --------------------------------------- -------- f ti - - �- ------------------- --- ---------- ----- Final Inspection by: Date :y = SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M.