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FOR OFFICE USE: U1W ` 7-7 � APPLICATION FOR SANITATION PEn c -`- 1--------�-- ------------ t Permit No-, `Q, i ---(Complete-in-Triplicate) ------ G ___ This Permit Expires 1 Year From Date Issued Date Issued A— ----------- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein F described. This application is made in compliance Coun y rdina ce No. 549 and existing Rules and Regulations: �.. f JOS ADDRESS/LOCATIONAL----- - CENSUS TRACT Owner's Name ------------- - -- --------- •- --�.----- -------• -------------------------------_----••------ --.-Phone _ o------- " Address ..-- . --------- City 7 ------ I Contractor's Nae -------------- ---------.License# V/-------- Phone ------------------------------ Installation will serve: e iden�eprtr�n nt House 1❑ Commercial ❑Trailer Court 0 I Motet ❑ Other - ------------------------------------------ . Number of livind units:-- Number -bedrooms . Z._ ____-_:_ �_-__ ____Garbage Grinder _________ Lot Size _____ _.____ Water Supply: P blit System and name _________________ --------------------------------------------Private Character of soil to ecle� 'bf 3 feet: ❑ Silt fl Clay ❑ Peat❑ andy Loam 0 Clay Loam ❑ .77 ,i pIN 1 Hardp ❑ Adbe ❑ Fill Materia] - - ___ - If yes,type ---------------------------- {Plot plan; showing-size of-lot,�}oca#'. st ' gelation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic nk�age pit permitted ' uiti ewer is available within 200 feet,) \ 6 - Material---------- ------------------- Liquid Depth PACKAGE TREATMENT [ } TIC TANK�[ } � Size________________ ________ city - ------------- Type --- ----------------- ------ No. Compartments ---------•-: istance to nearest: Well ----- ------------------------------ .� Foetndtion --- -----------------. Prop. Line ------------•-•------- LEACHING LINE No. of Lines ------------------------ L Fi �f��rh"x1i ------------------ Total Length ,................-•---...... 1 !j 'D' Box ------------ Type Filter Material .---------_----.._.Depth Filter Material .------- ................................... ________ Pro Line Distance to nearest: Well ______.______________. Foundation ____________ _ party ______.______.___._.__. E SEEPAGE PIT Depth[ ] p ---------. :------.Diameter--::_=:-=-.w___...E�Iumber--��-----�.�.__Y, -------- Rock Filled Yes ❑ No (] ---------------------------_Foundation ------------------- ' � Distance to nearest' W i -- --- --------------------------- ----Foundation ------ ------ Pro Line --------_-___ . Water Table Depth ___ _ liREPAIR/ADDITION frev. Sanitation Permit # : :=_r:.: -----•---.-------------------) Septic:.T.ank (Sp"cify Requirements) ------------------------------------ ------------------- .---------- `� Disposal Field Specify Requirements] -----•---- -- ' -------------------------- - - - i r ' ' =---• --------- ------------------------------------------ ----- ----V -;---------: E! (Draw existing and required adds#i ton reverse side) hereby certify tat I have pripared this applicaion and. that the work will be alone in accordance with San Joaquin County Ordinanc s, State Law , and Rules and Rlq�isf fi�AD of toe San Joaquin Local Health District. Home owner or licen- sed.agents signature certifies t;e following: k "I certify that in ihe performarIce of the work for which this permit is issued, I shall not empley any person in such manner J as to become su 'ect to Workman's Compensation laws of California. Signed `t t ---- 9 s? -- _ypOwner ii s r By. ------------ ------- - --------------- Title ----------- -N-------- - - - --------------------------------------- (if ther than owner) �( ? FOR DEPARTMENT USE ONLY (� APPLICATION ALCEPTED BY -- ---- ---------------------------------------------------------------- DATE -- � 7 N ' BUILQING PERMIT lSSl7ED - -- - -- --� - - ...__v__--- _ _:____-BATE � -------------- r--- ADDITIONAL COMMENT ---------------------------------' p ------------r--------'=---- --=----------------- -- --------------------------------------------------------- �- s•- ------------- -------------- ---------------- ----- -- ------- ------------------........----------- ------ -------- --------• ----------------- =:---------------------------------- -------------------------- Final inspection by: ----- !_ __-- ----, - Date ------------ � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M