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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _754 ------------- ---- This Permit Expires 1 Year From Date Issued i Date Issued A4plication 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 . 549 and existing Rules and Regulations: JOB ADDRESS/LOC�TIO�N-- ,4---- c Ilrls CENSUS TRACT . Owner's Name _2,_-- -------I-( f f ti= --•---------•--------- Phoney ------ Address City ------------------------ Contractor's i Name _r,.. r----- _-..� -- - -- ----- ------•License # �. Phone _--!_;, 4 �!-. 1 � I Installation will serve: Residence []Apartment House' Commercial :[]Trailer Court '❑ t t - ✓ T Motel ❑Other -___- __. Number of living units: _ mber of edroo s ____________Garbage Grinder --------___. Lot Size ' "____________________ aa.. ii �. Water Supply: Public System and name --- -----1�. -------------------------------------------------------------Prate ❑ Character of soil to a depth of 3 feet: Sand'[:] Silt❑_ Clay ❑ Peat❑ Sandy Loam ❑ Clay LooM';❑ Hardpan ❑ Adobe' Fill Material ----- ------ If yes,type ------------------------------ (Plot _______________ --____(Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) ti NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT { ] SEPTIC TANK' Slz _ �, / --------- --- ----- Liquid Depth ----Z/ Capacity _+�_________ Type`j �_ Material _____ Na. Compartments --------- Prop. Line Distance to nearest. Well --- � �/--_--.- - Foundation 11 LEACHING LINE { ] No. of Lines -----CR Length of each Total Length __---•4�4 D"Box ____ -___ Type Filter Materia! 5/A COC*Depth Filter Material / ___'.. i Distance to nearest: Well �-_ Foundation _. _ ----_--____ Property Line ____ ----------- ej SEEPAGE PIT [ ] Depth ___{, _► _-___._ Diameter_______ Number __._____.�____ _________ Rock Filled Yes No 0 Water Table Depth ---------16-2)-------------------- --------Rock Size ---•---- Distance to nearest: Well --------------_Foundation Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------.------} Septic Tank (Specify Requirements) ____________ ___ -------------------_--- - ----------------------- ------------------------- ------ { DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- - ------------------------------------------- ------------------------------------------------ ----- ------------------------------ -•--------------------.----------------------- (Draw existing and required addition on reverse side) 1 hereby certify that 1 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." _ Sig --------- Ow ly � BY itl� ----- ---------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ -----------------------------° -----------------------------_---------------------.---. BATE --- -'�Q16 BUILDING PERMIT ISSUED "----------------------------------- ---DATE --------------------------•--------------- --------------------------------------------------------------- ADDITIONAL COMMENTS --------------------------------------------------------- ------------------------------------------------------------------- ' •--- --------------------------- -----------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------- ------------- --- I . ' - -- Final Inspection by ' � ate ------ --- -------V - ------------ --- •--------------------------------- ------------- at ----- ------- � i SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'6B Rev. 5M