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FOR OFFICE USE- --------------------------------- SE: APPLICATION FOR SANITATION PERMIT ---- �._ -------- - ---------- ------ Permit No: -77,--.-1-�- ` (Complete in Triplicate) ------- --- --- Date Issued --- ---- This Permit Expires 1 Year From 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: JOB ADDRESS/LOCATION ._ _. /--- ----- -Y__Q-'w_1-r-IY---`fir- --------------------------- -----CENSUS TRACT -------------------------- Owner's Name __ h----- a _ ---------------Phone -----------------•------------------ Address -----------� L ------- �'-------- City ----------------- ------------------------ Contractor's --- ------------ ------------------------ Contractor's Name -----------------------------License # ----- --- ------ Phone --7 Installation will serve: Residence 21(partment House[] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- / Number of living units:---1------- Number of bedrooms _______Garbage Grinder - Lot Size -------- Water Supply: Public System and name -------------------------------------------------- ------------------------ ----------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand X Silt❑ Clay ❑ Peat❑ Sandy Loam a) Clay Loam ❑ Hardpan ❑ Adobe 0( 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,) j I �- ---. Liquid Depth ---- 4---------- �/ Capacity/2-00----- Type 1, C- sl materialCompartments ____fes______. Distance to nearest: Well ------------------------------------Foundation -- 6-�------- Prop. Line ---- ----------- �?6 LINE l�C No. of Lines �--------_----____ Lenges of each line--- -�__._------- Total Length _ __�-7�.�..-- 'D' Box . .__-- Type Filter Material -------------------- Filter Material ----- Distance to nearest: Well -------—-------------- Foundation ----- Property Line ........ SEEPAGE PIT [ ] Depth _ ------------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ WaterTable Depth ------------------------------------------------Rock Size ----------------------------•--- Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date _____---_____-____----------------) Septic Tank (Specify.Requirements) --•------------------------------------------------------------------------------- ---------------------------------------•--•------- DisposalField (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------- ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------ ---------I--------------------- ---------------------------- ------------------------------------------------------ - --------------------•--------------- i (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. Home owner or licen-sed agents signature certifies the following: ` "I cer ' y at in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner f as to be m s j ct to orkman's Compensation laws of California." Signed ------- --- ---r-- -- -'-------------- ----------------------------- Owner By ----- ------- ----- ---------------------------------- - ---------------------------------------------- Title ------------------ ---------------------------------------------------- f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE — BUILDING PERMIT ISSUED ----------------------------------- --- ---------------------------------- DATE _-. ADDITIONALCOMMENTS ---------------------------------------------------------------------•------------------------------------------------------------ --------------------------- --------------------------------------- -------------•---------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ ------------------------------------------------------------------------------------------- -------- ----- -- ------ - -------------------- --------------- Final Inspection by: ----- -- -- Date __-.- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M a