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.....FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 'S _.....---------------.... ...... d lComplete in Triplicalel Permit No. ...... _- -- -- ---•_....... --•......................................... This Permit Expires t Year from Date Issued Date issued ._.."j/_. f 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 ith County Ordinance No. 549 and existing Rules and Regulations: I JOB ADDRESS/LOCATION .. .. ..._..... �--._. ...-/..+r :.................CENSUS TRACT .......................... __._...:. Owner's Name ......a ......................................................................:Phone ........I....".........I_'...... 1 Address ...... ... City Contractor's Name _ License #J T_ _PA ... Phone installation will serve: Residence Apartment House Commercial QTrailer Court '❑ Motel ❑Other .-- ................................... Number of living units ..... ..... Number of bedrooms ..:....Garbage Grinder ............ Lot Size ...,10_.4-ne ................... Water Supply: Public System and name --------- . . ...... .......................•.........•..................:Private Character of soil to a depth of 3 feet. Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay.Loam ❑ Hardpan 2r/ Adobe❑ Fill Mpteria) .............If yes,type ............... ............ (.Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: INo septic tank or seepage pit .permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT SEPTIC TANK Size........_ [ ] ] •--....... Liquid Depth ......................... . Capacity -------------------- TYIi ..................... Material,:................ No,,�compartments .._--.................. Distance to nearest: Well ------------------------------a....:Foundation_------------.:..._..: Prop. Line --_--_-------•----- , LEACHING LINE ( ]. , No. of Lines -----------------_-_-- Length of each line-------•-------------------- Total' Length .................. 'D' Box ............ Type Filter Material .....................Depth .Filter Material ............:............................... Distance to nearest: Well ........................ ---- ---- .-:N-__-. Property Line SEEPAGE PIT .(..), 1 R.epth• ------------------ - Diameter _.--------------- Number----------------- ------------ Rock Filled Yes ❑ No 0 Water. Table Depth .................................................Rock Size ---.---------------.---••-------- % Distance to nearest: Well -------------------- ---••-.Foundation --—-..---.:__.-_. Prop. Lime ....---_- ------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _................_..........._._..) I Septic Tank (Specify Requirements) ........................:......................... .. .._ -_----_...___...... pisposa! Field {Specify Requirements) "__ ._` -------- -� _ --_____.___ 4 •----------- ------------------------------------ ----------------------------- -.-----------------•---•----- ------------- (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 I County Ordinances, State'Laws, and Rules and Regulations of the San Joaquin Local Health:District. Horne 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 Workma 's Compensation laws of California." Signed ------------------ _..... ---------------------- -- ------------------- d Owner c. . .G4S..ri"p Title t. BY - - --- - ._...------ (!f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- ------ r--------------- ---------•----------- ----------------- ---------. ---•--. GATE ..... 7 -�✓ BUILDING PERMIT ISSUED ------- ------- - ------------------------------------------ •----------- ------- •---.DATE-Y----------------------------- - ADDITIONAL COMMENTS ................... ------------------------ ............................... .--------- ------------- _..__--------- ----------------------------------------------------- ------------------------------.._..... - --- -•---•- . . -----------..._........---- ._. .... --. ....... ----------------------------- -•-----•------------------ Final Inspection b .................. P y= •-----_---:------•---•--- - ..r-- ..... Date .... .. ... EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT $�7�, 3M