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FOR OFFICE USES APPLICATION FOR SANITATION PERMIT iPermit No. -- -__-__ -------------- (Complete in Triplicate) ------------------------------ --- + ---------- This Permit Expires 4 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 compl_iance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ -_ ----CENSUS TRACT Owner's Nam K Phone Address --- --f .� Cit ---------- v Contractor's Name ____ - r� - ----- -- - ------ -- --- - - -- -..License # --`-��-d.:.��,�'�Phone --------------------- Installation will serve; Residence Apartment House❑ Commercial:[]Trailer Court i❑ Motel El Other -------------------------------------------- -------------- - - ------------ --- - - - C Number of living units_______ ____ Number of bedrooms ..__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 [n Clay Loam flRO-1— Hardpan ❑ Adobe ❑ Fill Material ------ If 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 [afo�' ,�`) l 40 Size- ¢ '� -------- Liquid Depth { --------------- N Capacity p v 1/0-b-0---•-- Type -------- ---- Material_ G A „-- No. Compartments 112..- ._. --------- Distance _Distance to nearest: Well ----------ro- -----------------Foundation --- J_9_..------_. prop. Line ---X----_-,_------ LEACHING LINEN%[ No. of Lines -------�"--------- Length of each line____1+P-p--_____._____- Total Length ----�60-.-i-_----•--__ 'D' Box I------ Type Filter Material ---S._R_•---_Depth Filter Material ------- / 0-r-----________________________ Distance to nearest; Wel! ___��---_____-- Foundation -------/�� i---____-- Property Line S.0 2 ___.--___ _ _ ----- SEEPAGE PIT [ Depth __ __----- Diameter - ,---" (( No --- Number ___---A________________ Rock Filled Yes ' I❑ Water Table Depth ----------------?a_-r----------------------Rock Size -� -�� -,�►� Distance to nearest: Well ---------- _61)f,___--______________Foundation ---- - _/ __-_-__ Prop. Line _ REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ---------------_--- ) 1 ----------- Septic Tank (Specify Requirements) _______ Disposal Field (Specify Requirements) ___-__--_______ --------------------------- - - -- -- ------------------------------------------------------------ - - ---- ------------- -------------------------------- ---------------- raw 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' ompensation laws of California." Signed ------ ----------------------------- 1 --- -- --------- - - ----------------------- Owner �• By -- ---------------------------- ----------- -- --- ----------- -- ------------------------------------ I other than owne ) F R .DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY ----------------------------------- ---------------------- DATE BUILDING PERMIT ISSUED ----------- --------------DATE ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ----------- --------------------- --------- ------- - ---------------------- ----- -------=--------------------------- Final Inspection by: r ---- ------'---------- .Date _ 71 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M