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f FOR OFFICE USE: r /� r r APPLICATION FOR SANITATION PERMIT } Permit No. � (Complete in Triplicate) _____________ This Permit Expires 1 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 des.cribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION i/ f ------ ----------- -- Phone 1 '----------------------------------- -- --- --CENSUS TRACT I -- ._.-�+�1-�------ Owner's Name __________ _- Address -- � � Phone - � ' -- ------- --- - --- ------ City ---------------- ------------------------- P Contractor's Name ------------- -•--____-- ------- ------.License # __jOa_S�/l Installation will serve: Residence VApartment House❑ Commercial:❑Trailer Court ;❑ Motel ❑Other 2 e,.V Of Number of living unit a-__/--__ Number of bedrooms ____,�___-Garb Grind r __- Lot Size ______ l _X-f�0_______________ Water Supply: Public System and name T------------------------- ---CA---- ------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand [ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe K Fill Material ------------ If yes, type -----------_-----___________ _ r ! (Plot plan, showing size of lot, locatibn_jof system in relationi to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic to-r k,or,seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK[JSpi..ze-----_��k`nn4_---_______--_________________ Liquid Depth __ /��--_-___,____- CapacityA_Y©a_:�Type -fR . -�__- Material_ tG._�---- No. Compartments �~ -- -----------= Dis st: Well ------------------ ----------------- Found --- ation ----------------- --.Prop. Line ------•- ------ LEACHING LINE [ ] No.ance to Weareof Lines ---------------- Length of each line-------_------------------- Total Length ,-----•--_-------------_---- 'D' Box :........... Type Filter Material ___________________Depth Filter Material - D stance to nearest: Well __ ___________________ Foundation ------------------------ Property Lime __________--____-_-____- ' SEEPAGE PIT Diameter _______________ Number -___.____._ I [ 1yrr p fn, s-t,--- ______________ Rock Filled Yes ❑ No rQ Water-Table Depth ---P---------------------------------- -------Rock Size --------------•------------ --- � � DistanceFo.,nearest: Wel! ---------------------------------- -----Foundation -------------- ---- Prop. Line -------.-----_--____-- ) ti _ REPAIR/ADDITION(Prev. Sanitation`Perm+t# -- ---------------------------------------- Date -------------------------------- ) I t i Septic'Tank (Specify Requirements) 1- r -- -------------------------------------------------------- Disposal Field (Specify Requiremerits)- - ------- -- { _. _ l ------------- -------- - ---------------------------- -------------- -------------- --------------------------- ------------------- ------------------------------------------ I _ t (Draw existing_and required addition-on reverse side) I hereby certify that I have prepared jthls 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. Home owner or licen- sed agents signature certifies the following: i "I certify that in the perfarmance'of the work for which this permit is issued, I shall not employ any person in such manner as to become subject°oto Workman's Compensation laws of o Signed ---------------- - . 1 1" O California."1ner � ---- A t l `_ ^ .,A. I BY ---------- i --- ----- title - ----- S - (If othert owner)! t - 1 fi FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY ------- .t -- - ---------------- ------ --------------- DATE --- BUILDING PERMIT ISSUED . - '" DATE ----------------------------- ADDITIONAL COMMENTS -- ---- __°- ------------'----- ------:__---- -- i -------------- -------------------- ------------------------------------------------------------------- -- -- --------------- --------------------------------------------------------- ---- --- - ----------- -- --- -------------------------------- - - - - ------- Final Inspection by: -------------------------------------------- ------------- `-- -- - ---- --- Data + ( tiSAN JOAQUIN LOCA HEALTH DISTRICT ``"' t f', E. H. 9 1-'b8 Rev. 5M r �