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I e ' EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ---- ---- - ------------- ------------------------------------ (Complete in Triplicate) ------ -- ------- ------ Date Issued ��---- -- ------------------------------ ------ I 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 compli ce with County Ord'na ce No. 549 and existing Rules and Regulations: y -------- ------CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION Owner's Name ' -------Phone - 'o Of --------- Address --------- City -- -------- -----------------------�,----------------- - - ---------- ------- ---- -- - - --- Contractor's Name ---------- ------ -�------ -- -----License #f. .S'/ Phone -. Installation will serve: Residence XApcirtrnent House-❑ Commercial :❑Trailer Court i❑ %L f Motel Other ---- -------------- Water Supply: Public System and name=_"""-___ " I Garbage Grinder Lot Size Number of living units:___ "-__.•Number of bedrooms `i i Private of 3[fee�:, Sand' Silt CI Clay,------------------Pri to pp Y. y -------------------------- -------------------------- . Character of soil to a depth ❑ ❑ ay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ I Hardpan l?L Adobe f�, Fill Material ------------ if yes, type --------- ------------------ F. t (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 15 NEW INSTALLATION: (Nouseptic tankror seepage pit permitted if public sewe r is available within 200 feet,]Ei� PACKAGE TREATMENT [ ] SEPTIC TANK ize----- ---------------------- Liquid Depth --_ :----- 1 _- No. Compartments Capacity] .;;� Yp ♦ p T e Material Distance ti nearest: Well ------0--- ----------------- fFoundation -----�©------------ Prop. Line ""l 1. I- ---- ""-- Length of each line --lu7?-------------- Total Length ,-- --------•----•-pq LEACHING LINE No. of Hnes.- 'i+v / Depth Filter Material ----- -5 U: Box -___-{ _- Type Filter Material "--- P �_- 0_-' '--""---- Foundation __--LO"f------- Property Line -"l�J"-- --_--•- {: :Distance�to.nearest: Well --- """"_ •r► ' �." Rock Filled Yes V No & SEEPAGE PIT Depth...... ----- Diameter - ---------- Number ----------��-- �fa-�rx � Water Table Depth ------------------------------------------------Rock Size - / - ---------- i . - a - nce to.nearest: .. el Foundation -��:f'' Prop. Line -�D- -----.. iDistance to.nearest: Well ____"-1�----- ----------------- .... REPAIR./ADDITION(Prev. Sanitation Permit# ----- ----------------------" `-� i� " Date ],R i� ib . ---------------- SePtic Tank (Specify Requirements 5 - - -------------- - -------------"".-.--_----------- Dis osal Field (Specify Re uirements) 17� A -- -------- - ------------ ------- ---------------------- ------------------------ 1 --------------- �- - ---- - ------------------------------------------ ------------------- `---- I , - - ------ - - - - - - { (Draw existing and-required addition_on reverse si e} € f I hereby certify that 1 have prepared this application and thof-the work---will-,•be-done-�inwlaccordance with San Joaquin f ` 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: t "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 ---- -- - --- ---- - - ---------- Title ---- --- (If of r han owner) . ry FOR DEPARTMENT USE: ONLY - ---------- APPLICATION ACCEPTED BYi--- y-`--- - `---- ------------------------------------------------------------ DATE BUILDING PERMIT ISSUED --- ---------'------ t --------DATE ---- ------------------------------------- --------------------------------------- ADDITIONALCOMMENTS -- ---------T --------- ---------------------------------------------------------------------------------------------------------= E --------------------------------- ------------- --------- ------------------------------------------- f --------- - ----------------- - ---------------------------------------------------------------------------------- --------- -- ----- -- ----------------------------- Date /fl ?- Final Inspection by: .- --- - 1 ------------------------------ # SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M '