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I FOR OFFICE.USE: APPLICATION FOR SANITATION PERMIT fNo. y �. ! - ----- --------- ------�J-YS---- Permit � (Complete in Triplicate] 1---- - . Date Issued ��f_30 This Permit Expires 1 Year From Date Issued -------- ---------------------------- - r 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 Ordinonce No. 549 and existing Rules and Regulations: .... t"� •.:_ .., ,'`•-1'% --T - CENSUS TRACT ------------------ --- JOB ADDRESS/LOCATION''`-r" -� �- - l ire I - e '4 � Owner's Name Q '�----�---- -- Phon --------------- Address -- -n- �� ' . --------------------- City ----- ', .---- -- �" ! �J s ----- -------- License # lC �---- Phone Contractor's Name ------------ -- ----- --- - -------=------ - ----------- Installation will serve: w Residence" partment House❑ Commercial ❑Trailer Court 0 r Motel ❑ Other ------------------------------------------- i -- i -------- Lot Size Q it - ------- Number of living units:___...__.- Number of bedrooms ""� --Garbage Grinder " �------�----- --- -- `� Private ❑ Water Supply: Public System and name -___ . . --. _. _ _-- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy'Loam ❑ Clay Loam "❑ Hardpan ❑ AdobeV Fill Material ------------ If yes, type ---------------------------- (Plot _-----..----------------_]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,) Oq PACKAGE TREATMENT [ } SEPTIC TANK'[ ] '--- Size----------------------------------------- ----- Liquid Depth -------------------------- j Capacity w T e - Material--------------------- No. Compartments ---------------------- R Y ------------- Yp �.t-' Foundation .-------------------- Prop. Line ---------------------- isDtance.-to neprest: Well ____.._.-_- --- LEACHING LINE [ )i No.of Lines ------------------------ Length of each line--------------------- ------ Total Length i 'D' Box -----=-•-'Type Filter Material --------------------Depth Filter Material --------------------------------- ---------- I Distance to nearest: Well ------------------------ Foundation ........................ Property Line ------------------------ SEEPAGE PIT [ ] Depth - Diameter ............... Number .-----" Rock Filled Yes E] No >Q Water Table Depth ------------- ----- ------Rock Size ----------------------- -------- Distance to,nearest: WeIJ----------------------------------.----Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- I y Septic Tank (Specify Requirements) --------------- � --- ------------ . --------- ------�---------------•.•---------------------------- P -- --------------- ----- -- ----- -------- - --- --------------------------------------------- ------------- Disposal Field (Specify Requirements) ._---- -- . _ � I ------------ --- --- ---- -------------------- -- ------------------------------ ----=-------- --------------------- ------- _ (Draw existing a'nd'.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, l shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." 3 Signed ------------------------ --- -------- - -------- - _ Owner ` Title --------- --------- ------------------------ BY = - ---------------- (If other a owner) FOR .DEPARTMENT USE ONLY. APPLICATION ACCEPTED BY --------- -----�< -------------------------------------- -- --------------- --- DATE `' � - BUILDING PERMIT ISSUED--.—.---.= = = -_ _ --DATE -------- ---•----------------------------- ADDI710NAL COMMENTS . . ----- -----��-- --- ------ . - t ------ ----- - ' �� -------- ----------------- �-f7 - - - --- ------------------------------ ----------�`"--�°� �----L- ------- ---------------------- '-- - ------ --------- Final Inspection b ------------------------------ Date �z-� SAN JOAQUIN LOCAL HEALTH DISTRICT 1d 9 1.'AS Rev_ 5M _