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FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT ----------------------------------------------------- Per No. {Complete in Triplicate} ___--____--------------- 4V This Permit Expires i 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCTION ._6�-�f --------p-;-----f�-- -------------------------- --------------- a--,---- CENSU5'TRACT •------------- ------------ Owner's Name --- 1/ / --•---------------------------------------------- -- --- -----Phone ----------------- Address ---------- -'----- - f -.-- -- ----- l ------------------------------------------ City r✓ T Contractor's Name `' License Phone Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other-------------------------------------------- J . Number of living units.----/----- Number edro ms __� _`Garba a Grinder .__ Lot Size _ Ql ____-....-. Water Supply: Public System and nam __ L.�.� ___. ---- Private ❑ Character of soil to a depth of 3 feet: Sand❑ ilt❑ Clay ❑ Peat❑ Sand loam Clay,Loam Y ❑ Y ❑ Hardpan ❑ Adobe ill MQterial ------/P�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[ ] Size------------------------------------------____-_ Liquid Depth --------------------------- Capacity ---------- Type -------------------- Material---------------------- No. Compartments -------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ........... LINE [ ] No. of Lines -_________________ ---- Length of each line---------------------------- Total Length .......... Type ------------------- Depth Filter Material _______________ ___ - 'D' Box ------___--- T e Filter Materia! ------------- _ - ---------------___-- ; Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ---------.______________ SEEPAGE PIT [ ] Depth -------------------- Diameter ______________ Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- 1 t. Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ----------.-______--__ ' REPAIR/ADDITION(Prev. Sanitation Permit# - ----- Date --- --------- ---- -- ---------) t Septic Tank (Specify Requirements) ------------/---�-------- ------------- Disposal Field (Specify Requirements) -_-f 4 ------sr--�-- - -•---------------- =-- --- ------ f-,�--�� ---- ---:-- ------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 / 1 By - - -------- - --1- l----�---------------- Title . -----� ✓-------------------------------------------- ] (!f other tha ner) /F_4AEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ,.� ----- ------------------------------------------------------------- DATE BUILDING PERMIT ISSUED ------------------------------------DATE ------------------- ----- ---- - --- -- ------------------------------ - -- ADDITIONALCOMMENTS ------- ---------- -- --------------------------------------- --------------------------- -- -- -------- ------------------------------------------------------------- -------------------------------------------------------- ------------------------------------- Final Inspection b Date - ---=- -=- ------------------ P Y' --- -------------------------------------- OAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M