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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..................................... .............. ... - .�- (Complete in Triplicate) Permit No. --• ate) ... - ------------------ ----•----.....---•--....... ........ ................... This Permit Expires 1 Your from Date issued Dab 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. 54.M and exlstinq Rules and Regulations; 5U�T 7 �c %i�cF' CEN A RCT ....,... B ADDRE55 LOC, Owner's Name Gc Phone r�-. -....... ........................................!` .............. Address ... - .. : ......... City ..,�Z��C!' .. . .... ..... r Contractor's Name _� i�i2f- �.� "� ......... Phone Installation will serve: Residence(,Apartment House❑ Commercial ❑Traller Court Motel ❑Other ............................................ / Number of living units:..._-1..... Number of bedrooms ... .Garbage Grinder ............ Lot Size Water Supply: Public System and name ........ ......................................................................................................Private Character of soil to a depth of 3 feet: Sand]] Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam Hardpan�K Adobe ❑ Fill Material ............ If yes,type_............. ............ . (Al {Plot pian, 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 f ] Size.........................I....................-. Liquid Depth .......................... Capacity -------------------- Type -•------------------ Material......------ --------- No. Compartments ---------•--. Distance. to nearest: Well ....................................Foundation ...................... Prop. Line ...................... r LEACHING LINE ( ] No. of Lines ........................ Length of each line............................ Total Length ............._... .......... 'D' Box ............ Type Filter Material ....................Depot 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: Wel! ............ ..........___..........Foundation .................... Prop. Line ...................... REPAIR/ADDITiON{Prev. Sanitation Permit# ............................................ Date ..................................I a Septic Tank (Specify Re uirements I ...OCKL_ .x :.. -------- ----------•------- .... ... -------------------- �. �t Dis osal Field S eeif�y; Re uirementsl ---�.e?.: . .�-----------------------------�----........-- --- -- -- ---....---_9� .I------�.�..--------._..., P IP � q ..---•----------------------- ,� --- ----- ------ ----•- --- ---- ..................................................... ------------------------- ------------------------------ ------------...................I................I.,.............. ------I...................... JDraw 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 perFo ante of the work for which this permit is issued, i shall not employ any person in such manner as to becom�subiect to VI�For man's Compensation cos of iifornia." ti. Signed .. . ... \, _ By ..._.. - - ---`-. .... Title .... ._ rte- ... .................................... (if other than owner) FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY _._. ...- ----------•------------------------_ ----------..._....--------. DATE / .-�/.- .......... -----. BUILDINGPERMIT ISSUED ---........................ -- ---- - -------- --•--------------------------•--- --_--- __---DATE .......................................... ADDITIONAL COMMENTS ..-........ ............__ -------------•------•- - ..._. -------------------------- -----------------------------------------------I...................... .,..._._...-•--------------......----- ...... ......... ....... --------- ----------------------------- -•--•--- ........ Final inspection by Date .... EH 13 21 1-68 Rev- 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M