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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I �, ---- ------- �- Permit No. 71 7 (Complete in Triplicate] i ----=--------------------------------------------- z� This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: ' JOB ADDRESS/LOCATION 2-F-3-------- ----ez�,,,120Z,-------------------------------------------.----CENSUS TRACT `_r`'._F._._.------.---- y� Owner's Name --------- /_4 ------- ------------------------ Phone ----- --- -- ------------ ---- _ Address ---- [ _ - ---- --------------------------- City f ' Contractor's Name , ----------------------------------------------------------------License # --------- ------ Phone ------------------------------ installation ---------------------- •-installation will serve. ResidenceQg Apartment House ❑ Commercial :❑Trailer Court ',❑ . 9 Motel ❑ Other ------------------------------ ------------- 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 ❑ Clay 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 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK Size- __ '_________________________ Liquid Depth _�C----..__..__,._-__ � i Capacity& v________ TypeMaterial__f ------------- No. Compartments '................. Distance to nearest: Well --__Aq--------------------------Foundation _�D--------------_ Prop. Line A - ---------- LEACHING LINE [ No. of Lines -!?'�------------------ Length of each linelTI---------------------- Total Length -__ ----------------- ' Ir 'D' Box __s__�> Type Filter Material _t-&----------- Filter MaterialA1______________----------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line _____________-__._.___ SEEPAGE PIT [y(] Depth ----------- Diameter *_ _3-------- Number ________ _____________ Rock Filled Yes,2 Na C) Water Table Depth ____ -�� Rock Size _' '___________________ p 9 .............. r ---------Foundation /0"-:---------- Prop. Line -S_.•--...•..._-•- Distance to nearest: Well fr�________________________ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) i SepticTank (Specify Requirements) ---------------------------- -----------------------------------------------------------------•---------.---------------------------------- Disposal Field (Specify Requirements) -------------------------------------- ---------------------------------------------------------------------------------------------- @ w ------=------------------------------------------------------------------------------------------------ = ------------- ---------- ------------------------------=------------- ---•-----------------------------=------------------------------------------------------------------------------ - -- (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 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 sub*beg to Wo kman's Co nsati.on laws of California." - a SignedOwner --------------------------- By ------ ------ ------------------------------- --------------------------------------------------------- Title ------- ----- ----- ------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- 1------------------------------------------------------------------. DATE .' " ----------- i BUILDING PERMIT ISSUED ----------- ------------------------------------------------------------------------------ --------------DATE _...--------------------------------------- ADDITIONAL COMMENTS --------- ----------------------------------------------------------------------------------------------------- -------- -------------- ------------------------------•------------------------------------ --------------------------------------------------------------- ------------------------------------- ----------- ------------------------------------- - -------------------- - Final Inspection by: -+ _ Date __. ._ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev, 5M 4