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APPLICATION FOR SANITATION PERMIT 7 t« No. (Complete In Triplicate) Permit .__....:_ �...�� Date Issued .... ........................ .. This Permit Expires 1 Year From Date Issued G 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. �i JOB AQQRI:SS/L TIO � CENSUS TRACT ....... Owner's Name ... .. .:..... . . t,r �,.�._.._. Phone . ... ... ... .................... .. Address _- -1�. .. .:.... city .......... Contractor's Name ._... . ....•:........ . .. ._..... `/�.._.`` -._......,License l .. Phone ............................... Installation will serve: Residence (,Apartment House 0 Commercial ❑Trailer Court 0 Motel ❑Other .......... i Number of living units:.......... Number of bedrooms .:._...__Garbage Grinder ............ Lot Size ...... �o Water Supply: Public System and name .....................................-•------------------------------------------................. ............Private Character of soil to a depth of 3 feet: Sand D Slit❑ Clay C1Peat[ISandy Loam 0 C lay 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 208 feet,) ' PACKAGE TREATMENT ( ) SEPTIC TANK ] Size.......................... .. Liquid. Depth ' Capacity ------------------- Type ----------•--------- Material...................... No. Compartments ....__............... . Distance. to nearest: Well foundation ---------------------- Prop. Line ...................... Lt► ! LEACHING LINE No. of Lines -_ Length of each line--------------- ., 1. l g ............. Total length ._............... ......... 'D' Box ...... ..... Type Filter Material ----------------Depth .Filter Material ............................................ . �j Distance to nearest: Welt ------------------------ Foundation -....................... Property Line ""..-------_---------- " ' SEE=PAGE PIT ( } Depth -------------------- Diameter ................ Number ............................ Rock filled Yes ❑ No �] Water Table Depth ------------------------------------------------Rock Size �{ Distance to nearest: Well ................. ....................Foundation ........ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------:---------------------- Septic Tank (Specify Requirements) ------------ ------------------------------------------ ........ -. ............... 1 Disposal Field (Specif Requirements} 4- f--•-- t--------�d.4 - ..:.. . .......... �=[, 2-- ----------------------------------------------------------------------- (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 I County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Home owner or Iicen- sed agents signature certifies the following: 1 "I certify that in the performance of the work for'which this permit is issued, I shall not employ any person In such manner { l as to become subject to War n's Compensation laws of California." d + Signed - F_ _� ------ Owner i4 �- FBy ----- ------------------------- --- ------- --------- -- ---- L ----•--- Title -- �, ----------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. .. �V rz�a?� DATE FBUILDING PERMIT ISSUED ----------- ......DATE ...... ......... •--•-. -------•------ --•------- - ADDITIONAL COMMENTS . . ----•--- ......... - -------- --- -- ----------- -- ...._.... ........ r=�� y'� a--------------- ------------ -- final Inspection by: ---------- f' .. _<:. _T Date .... -------- - .`... 13.2 1-6 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7a 3M i