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FOR OFFICE USE, APPLICATION FOR SANITATION PERMIT (1 ............ ........................................ Permit No. ........4. .. (Complete in Triplicate) ...................................... - This Permit Expires 1 Year From Date Issued Date Issued ..7.-..... 7� 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 Regulationst JOB ADDRESS LOCATION ,. ...........CENSUS TRACT .......................... Owner's Name .. t/...... .. ......... .. ....I............ ... .............. ...................Prone .................................... Address ................... City .... ..........:........ ......................... . ... .. Contractor's Name .... . .....r. ....... ... .: License �• � ...Phone ........................::.... Installation will serve, Resi encs Apartment House[] Commercial ❑Trailer Court Motel []Other ............................................ Number of bedrooms >......Garbage Grinder ............ Lot Size ...... Number of living units:../........ .................... Water Supply: Public System and name ...............................................................................................................private . Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loom 9---' 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 j Size..................................... . Liquid Depth Capacity •................... Type .................... Material...................... No. Compartments ..................... N Distance to nearest: Well ...................Foundation .... Prop. Line J LEACHING LINE [ ] No. of Lines ........................ Length of each line._..............•-.......... Total Length ............................ 'D' Box ...........- Type Filter Material ....................Depth Filter Material ............................................� Distance to nearest, Well ........ Foundation Property Line ' SEEPAGE PIT [ ) Depth Diameter ................ Number ............................ Rock Filled Yes © No ❑ Water Table Depth ..---•-•........................................Rock Size ................................ Distance to nearest, Well ........................................Foundation .................... Prop. Line ........................X REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) Septic Tank (Specify Requirements) ....... ...... ............ ...................................................... .................. Disposal Field )Specify Requirements) I( . ........ ....... ` ....... © .................... ..... ... �............. X� ------........------............................................................•---................... ......................................................................................................_............................................................•.............................. . (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 Ilten- 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 .............................. .. .TC►wner ... N By .................................... .. . . ... ,... .................... .... ills . .. . . .... ......... . ............... ....... (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 6.. . .., DATE ....... ... BUILDING PERMIT ISSUED ....--- ............................:.........................,.......................................DATE ........................................... ADDITIONALCOMMENTS ........................................................................-........................................................._........................... ........................ .................................................................1..........I..................................�w. :....:.., CW Final Inspection by. .............. ............................................................................................. ate SAN JOAQUIN LOCAL HEALTH DISTRICT C. E. H.13 241•'68 Rev. 5M - 7172 3 M