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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------------ (Complete in Triplicate) Permit No. --------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued __ ------- 7.. 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: /a 5y U- --��-------..d.[.C_.'f'''� ENSUS TRACT _ —Sl�------- JOB ADDRESS/LOCATIO, .-_.____._________________y____- __ Owner's Name --------Com'_-------- �` ---------------------------;; ------------ Phone ------------------------------------ Address ------------f_r� l r. - - - --- - - --- City _ _ ----- Contractor's Name ------ __-�- ----- ----------- ---.License # � j ?� Phone ------------------------------ Installation will serve: Residence eApartment House[:] Commercial ❑Trailer Court ;❑ Motel ❑ Other _--_ ------------------------- Number of living units:------ ... Number of bedrooms __20 --_--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 Loam ❑ Hardpan ❑ Adobe ❑ 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.) PACKAGE TREATMENT SEPTIC TANK:[rf Size.,5 rr/,O-.X_5_______________________ Liquid Depth y_.�_��____-,_____ Capacity .1�.�da'�Type �+ __-__ Material - r---- No. Compartments __egn........ Distance to nearest: Well ---------- `C__'-------------------Foundation -----!a___'-------- Prop. Line --- ------------ LEACHING LINE [rJ No. of Lines ------ -- _ 'r--_ Length of each line---____--eW--`----------- Total Length ___ ---------_--- 'D' Box ._y...... Type Filter Material ---- Depth Filter Material -___ ______________________ Distance to nearest: Well ----457��-/.--------- Foundation ------/_ Property Line ---_-r_----_____________ , SEEPAGE PIT [ Depth ___ ` D-� Diameter _' '........ Number ----------Z-------------- Rock Filled Yes 21" No ❑ Water Table Depth �-- ------------- Rock Size Distance to nearest: Well ------------A0g!_`----------------Foundation ----«__`.------ Prop. Line --- ------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- _ Date ----------------------------------I Septic Tank (Specify Requirements) ------------------- ------------------------------------------------------------------------ ,.--------------------------- Disposal Field {Specify Requirements) --------------- ---------------------------------------------------- --------------- - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- {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 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." Signed ------- ----- ----- ---------------------------- Owner 9 By -- -------------------------- -------------- Title ---------- --- -- ----------------------------------- ------- - -- ------ -- (If other than owner) It OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -.-_l_ -------------. DATE ....5�_ 4` 7f BUILDING PERMIT ISSUED ------------------------ ---------------------DATE .------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ - --------------- ------------------------------------------------------------------------------------------------------------------------- -- - ------ ---------------------------------- - - ---------------------------------------------------- ---- ----- -- --- -------- Final Inspection by: - =--- ----•----------------- -------------------- Date - 7= l SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M