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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --=-------------------------- Permit No. * (Complete in Triplicate) � --- ---------- -------------------- --------------- w -. : Date Issued y._ l`6-f `Skis Permit Expires 1 Year From 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/LOCATI N 1j� {- .. ------ ------------ ---CENSUS TRACT -------------- ------ ----- Phone Owner's Name _._ . -__ - -- -- Address ------------------- - _ City ------ ----------------------------- --------------------------------------- License ------------------------� ------ License # ---------- ---------- - --------------------------- Contractor's Name --- �. Phone �� .7= ,. Installation will serve: Resid nce ❑ rtment House❑ Commercial :frailer Court Motel ❑Other -------------------------------------------- 115 6 --------- 1/ Number of living units..----------- Number of bedrooms ....____...Garbage Grinder ._.____....ILat Size __ s3-_d --------- Water Supply: Public System and name --------------------- ----------- --..----- -------------------- --------•------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam El 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.) p see age pit ed if public sewer is available within 200 feet,) PACKAGEATREATMENT { ] septic tanKITM k air [ ------------ ------•--------------- ------------ Liquid Depth ----------------- _L_ Capacity ------ -- Ype -------------------- Matera ------------------= . artments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------_-_------ I LEACHING LINE [ ] No. of Lines --------:=------------- Length of each line---------------------------- Total Length ------------ .- -------- , 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------------- Distance .........................--_---------Distance to nearest: Well --------- -------------- Foundation ------------------------ Property Line ---..._...---.-......... r r� SEEPAGE PIT / Depth .... .... ---- Diameter _...___......__ Number ----- ------I------------- Rock Filled Yes 0( No i❑ Rock Size _. (i Water Table Depth - - �-- =-------- ----�--------------------- / ------------- -- ----------------- ---- ---- ------ Distance to nearest: Well ----------- .��-----------------Foundation ---/ ._�_ Prop. Line ..._______._____ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------•-------) Septic Tank (Specify Requirements) ------------- ------- --------------------------------r---------------------------- Disposal Field (Specify Requirements) -------- -- ----- ---------------------------------------------------------------- -------------------------------------------------------------------------------- ------------------- (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 subject to Workman's Compensation laws of California." Signed - Owner -------------- ------------------ Title ------611C_Ft�_ ----- --------------- BY --- -- f ter than owner) R .D ARTMENT USE ONLY U APPLICATION ACCEPTED BY ------------ ------f---------- ---- _. - DATE f �/ �� BUILDING PERMIT ISSUED -------------------- --------------DATE ----- ------------------------------------ -------------- ADDITIONAL COMMENTS ----------------------- ------------ ------------------------- ---------------------- ---------------------------------------------------------------- -------- ------------------------------------------------------------------ ------- -------------- n ------ Final Inspection b .--- ----0�- Date 6 SAN JOAQUIN LOCAL HEALTH DISTRICT E E. H. 9 1-'6$ Rev. 5M .