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FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT Permit No: -- (Complete in Triplicate) This Permit Expires ] 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 F described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: / I '`u''J, ---------------CENSUS TRACT - -�=-------••-------- JOB AbbRE55/LOCATIO - �Ej Owner's Name ; p ----- phone r x Address � r?--- 1C�C •---------------- City ----- �f-------------------------------------..-------------- i ----------- ------ ---------------- Contractor's Name ---- ---- -- ---- -- - ,�--------- - ` ------License # k �"� Phone -----_---------------------- Installation ---------------------------Installation will serve: Residence [Apartment House IE] Commercial [ Trailer Court ❑ t Motel ❑Other -------------------------------------------- i 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'Q Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay-Loam.❑ Hardpan ❑ Adobe'®r 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 feetJ) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------ ---- ---- Liquid Depth ...------------........--- Capacity ------------------ Type -------------------- Material`--------------------- No. Compartments ---------•- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop' Line ---------- N LEACHING LINT= [ ] No. of Lines ------------------- ---- Length of each ;line---------------------'-- Tota! Len gth =-------- o 'D' Box ------------ Type Filter Material ------------ -------Depth Filter Material ------------- ----------------•----- -- I Distance to nearest: Well ----------------------= Foundation ----_--------------,- Property Line -------------------_-- 4 SEEPAGE PIT [ ] Depth __._ -- ------------ Diameter -------- �-___ Number ____________________________ Rock Filled Yes ❑ No i❑ Water Table Depth ' "A"�� ----- -------Rock Size -------------------------------- ' Distance to nearest: Well,_�_,----------------------------------------Foundafion"--------------•---- Prop. Line ----_----___:-------- i REPAIR/ADDITION(Prev. Sanitation Permit#:,-*---- ----------------------------------- Date ------ --------------_---------- i Septic Tank (Specify Requirements) `� ' lDisposal Field {Specify Requirements) -- ma y__= ff -% '-`-�--------" ---- ------�- ' Af' `"t'.'Sr-- -------=---------- --------•---------- �. Y' - i . _ ----------------------------------_--------------..---------- .------________________._-__-_.___________________-______________________._____.________-________.-.___._______________.-_________"_._____- (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance:with SQn Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne 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." k Signed -------- ----------- r Owner ,��a------------------------ ----------------- By -------------------------- --- -------` --------------------- Title ---------- (if (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -------. DATE / - "---- ----- - -- -- -- ------- -- --------------------------------------- BUILDINGPERMIT ISSUED ------------------------------------------------ -----------------------------------------=--------------DATE ------------ ------------------------ ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------------------ ---- -------------------------"---------------------------- ------------------------------------------------- ------------------------------------------------------------------------------•------------------------------------------------- ------------------------------ -- -- `-------- ---------------------------------------------------------------------------------------- - Fina! Inspection by -- - -------- - -------------------------------------------------------------------------Date [ _-- � ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M