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FOR OFFICE USE: ► APPLICATION FOR SANITATION PERMIT �. _� (Complete in Triplicate) Permit No: ---__-_.__- _•, ------------------------------------ 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulatonsrein i JOB ADDRESS/!_OCATION __1v8F( C�c? ---------------------------------------- ------CENSUS TRACT --- Owner's Name -+!- IX"w----`.D4441M------------- -------Phone Address Contractor's ---- � Contractor's Name -- �.1� ti�� Ci ------------------------------------------ - + ------------- �[��. License # gl------ Phone 'A g Installation ----------•------•- will serve: Residence Apartment House{] Commercial :❑Trailer�Court Motel -] Other - Number of living units------V_--- Number of bedrooms ------------Garbage Grinder --_____-- -_ Lot Size -Water --------------- Supply: Public System and name _____ _A_ ----__ Private -----------_ ------------------------------------------------- Character of soll to a depth of 3 feet`4� an 'El 4,Silt fl Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ____________________________ (Plot plan, showing size of lot, location of system^ in rel9tion to wells, buildings, etc, must be placed on reverse side.] +� NEW INSTALLATION: (No septic to nk or seepage pit permitted if"publicsewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK [ ] 'Size__ .____________________--__ -__• Liquid Depth _______--_____- ------- 4\ Capacity ------'�- 'l Type-------------- Mat-eTrial-------------------= No. Compartments ------- Distance to nearest: Well -------------`-- - _ --- ----------.Foundation ---------------------- Prop. Line -----.---------------- [ ] No. of Lines ------------------------ Length -of each line----------------------------- Total Length .--_---------- LEACHING CINE -----•-------_- �� Type Filter Materia --------------------Depth Filter Material ----------- ------ ----------- Distance to nearest ` .ox - -- --- -- T _ : Well -----------------=------ Foundation ------- ---------------- Property Line ------------------- SEEPAGE PIT �� + - ��--- [ ] Depth ---._.------------s Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table- Depth -------------------------------------------------Rock Size --- Distance to nearest.. Well-"_``-_-- - _•--'',- -:_Foundation -------------------- Prop. Line ----- REPAIR/ADDITION(Prev. Sanitation Permit# --------_-------------------------------->--- Date ) Septic Tank-(Specify Requirements) ___________________r_ ----------------------------------- ------------------------------------------ Disposal Field (Specify Requirements) ---------------------------------- ------------------------------------" o----- ------------- --- ---------------- ---------- ---- --- ------ ! �--i ��'- --------------------------------- - ------- --------------------------------------------------------------------------------------- ----------------------- IDrdw ekistin" and re uiftcl-addition ori-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 lRules 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 oUthe 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 t � �'e By ------------- --------=--- Title ---------- ----------- ------ ------- ----------- -------------------- (If other than owner] -� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --_ _ ._ _ DATE __-- ------------------------- BUILDING PERMIT ISSUED --- ------_i-__-_--- ----- --- --- -- ---------------- ------------------------------------------------ -- -_."_DATE AL COMMENTS ------------------------------- ------------------------------------ ----------------------------------------------- ----=------------------ - ---- --- --------------------------------------------------- -------------- - ----------------------------- ----------- ---------------------- ---- Final Inspection by: 3- - -- --- - --------------- -- ---------- - --------------------------------- --- - - - - - - - - -- - - - ------------ --.Date -4-_y-k ��_------- -•• ----- SAN JOAQUIN LOCAL- HEALTH DISTRICT E. H. 9 1-'b$ Rev. 5M