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i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------------------, -- - - -- - --- (Complete in Triplicate) Permit No. -- ---- ------ --------------------------------------------------------- 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 ADDRESS/LOCATION i_ C1_�------(,A)0 5;( f4 -__-1 L'`- _._------_CENSUS TRACT Owner's Name ---�--01 _U-eL__----- --------------------- ----------- -------Phone Address --- -- ------------------- ---��----------- 7 City -------- Contractor's Name ------ ---------------------------------License Phone --------------------- Installation Installation will serve: Residence NrApartment House❑ Commercial ❑Trailer Court l❑ Motel ❑ Other -------------------------------------------- Number of living units:------`i'---- Number of bedrooms ---2.,---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 I ] SEPTIC TANK'[ j Size___________________________________ ____________ Liquid Depth ------------------------- Capacity -------------------- Type -------------------- aterial------------ --------- No. Compartments ------•--._....----.-- Distance to nearest: Well ___________________ ______________Foun ation ___ _______ Prop. Line ______________________ LEACHING LINE [ j No. of Lines _______________________ Length each line_.__ ____ -- Total Length -------- ------------------- 'D' Box ------------ Type Filter Materi -------------------- epth Filter Material --------------------.----------------------- Distance to nearest: We!! ___________ ____________ Found tion _____________________ Property Line _____.__._._____.------- SEEPAGE PIT [ ] Depth ____________________ Diameter -_____ Nu be --- Rock Filled Yes ❑ No I❑ Water Table Depth ------------ ----------------------- ----------Rock Size -------------------------------- Distance to nearest: Well _____________ _______________Foundation ------------------- Prop. Line ..___..__.._.....__.. ---------- REPAIR/ADDITION(Prev. Sanitation Permit# ..../-------------- ________________ Date __________________________________) Septic Tank (Specify Requirements) _ ----------- - -- -- - Disposa�Field Sp cify Requirements) ------- /_.ra�VC -- ----------- ------ ------------------------------- ----- ---36- --- W!_A - - ------------------------------------------------------------------------------------- (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed __ Owner -- - -- --------------------------- ---------------------------------- BY «` ` ---------------------------- Title --------- ----------------- ------------------------------------------ ---- --------- (If other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----�,,.)?-0--------------------------------------------------------- ------------------ DATE BUILDING PERMIT ISSUED ---------------------------------------------- ----------------------------DATE ------ - ---------------------------- ADDITIONAL COMMENTS ------- ----- -------------------------- -- ------ - -------------------------------------------------------- -------------------- ------------- ----------------------- - - ------ ---- - ---------------------------- --- ------- ------- ------ - ---------------------------------- Final Inspection b -------------------Date _-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M.