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FOS:-OFF`X-2 USE: V 0� APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: _..: ---------- -------------------------------------- ;. 1 _______________ This Permit Expires 1 Year From Dale Issued Date Issued iy -- 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 _,____ ___ ------- ------ -------CENSUS TRACT -------------------------- I Owner's ------ ------------------ Owner's Name i i ---------------------------Phone . - - --- - -- - -- - �� - Address ------ city �-------------------------- Contractor's -- _-------------•-,----Contractor's Name . _ _, ` �-Kr .License# Phone 1141 710116>____ t Installation will serve: Residence;K Apartment House❑ Commercial❑Trailer Court '0' i Motel ❑Other ---------------------------'---------------- t i • . Number of living units:___________ Number of bedrooms ---- Grinder ___ _._ Lot Size _ ______________________ Water Supply: Public System and name ------------------ ----------------------------= -- -------------------------------------------- -------------- Private Character of soil to a depth of 3 feet: Sand X Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe-❑ Fill Ma#erial ""-If yes, -pew_______________________ (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,) `" f PACKAGE TREATMENT [ ] SEPTIC TANK' Size-.-____ _rs _�. �Q_r � ------- Liquid Depth ------�--------------- i. Capacity _ DUr Type _ _ .__________ Materials __ No. Compartments . -- ___.:..__ Distance to nearest: Well ___ ------------ r Foundation ____��_____-__ Prkop..line LEACHING LINE No, of Lines __----___ff------------ Length of each line._.__.- 'e_7�Total Length=,_: lam__-_---__-.--__ K , 'D' Box _---!---- Type Filter Material -------Zq...r__ __Depth Filter Material _ ' . - ----------- - --------------------- i Q Distance to nearest: Well l - �--- Foundation ^� ) � -©- ------- --,�� ------- Property_Litre;,-=-�•--- _--_-__. - --• _ SEEPAGE PIT v Depth Diameter ________________ Number -------_--------------_-__-- Rock Filled Yes ❑.. No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance ------------------------- ----Distance to nearest: Well ---------------------------------f-------Foundation ------------------------------------ Prop. Line ....-- ............... REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------------------------- Date ---------------------------------- Septic -----------------------__ ---SePtic Tank (Specify Requirements) ------------------------------------------`-------------------- •-g--------- ''1----------------• •--------------- Disposal Field (Specify Requirements) ___________ _____ P !�,`t"- _-__- ---------- �- --------------- --- ------------------------- # ------------------------` ----------------------------------------------------------------- =' - ------------------- r - - ---------------------------------- - - ----------------- (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 Sha11 not employ any person in such mgnner as to become subject to Workman's Compensation laws of California." ' # Signed --------- ------------------ ----------------- -------------------- --------------- . Owner i -- Titte- ----z- _ By r t .. _ cr � y --------- - ------------ E other`thanrawner}�.--�-= ------------------------ i OR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY - J DATE --- __-1Z•'- a ;-------- } BUILDING PERMIT ISSUED ----- -------DATE -------------------------------------------- ADDITIONAL'COMMENTS',,.'_ ___ __ __ _ _ ________ I ,.--------- -------------------'�--= -- - - .. __ _.:�. k. _._- - ------------------------ --------- --- - ------- ----------------------------- -------- Final Inspection by: -.-_- -- - --------------------------- a. ------ -. __ -----_Date -------------------------------------------------- SAN -------- ---------- ----=--------SAN JOAQUIN LOCAL HEALTH DISTRICT elf 1Ri � E. H. 9 1-'b8 Rev. 5M r