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FOR OFFICE USE: i ' APPLICATION FOR SANITATION PERMIT . ----------------- ------- . • {Complete in Triplicate} Permit No: �7-�::_.�-�'___. . This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the Sa 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: ''IOB ADDRESS �C,AJTION . �f� I"/ " -------------------------------------------- ---- CENSUS TRACT Owner's Name - 1 -=--- (T___-- = Phone ------------------- ,a / 1'' Address ------ � '- ------f - '-- ------=- .-------- ----------------------- ------------ City p rf r Contractor's Name ----- / ---- --------- ----License # -�dd_c�d_ Phone ------------------------------ Installation will serve: Residence J Apartment House❑ Commercial :❑Trailer Court ;❑ Motelf]Other ------------ ------------ ----------------- Number of living units:-----f------ 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 E] Sandy Loam "Clay Loam El L ' 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[ ] Size-------------------------------------__-._ Liquid Depth -------------------------- Capacity ----------------- Type -------------------- Material---------------------- N Compartments ------------------_-- h E. Distance to nearest: Well ---------------------------•--------foundation ---------------------- Prop. Line ------•-----•--:------ LEACHING LINE [ ] No.--'of Lines ------------------------ Length of each line--------------------------- Total Length ___________•________________ �1 q -_$ �1 'D' Box ____________ Type Filter Material ____________:�____ Depth Filter Material _______________ _____ __ Distance to nearest: Well ____________________,:f_ Foundation ------------------------ Property.Lind __.______-______________ SEEPAGE PIT [ ] Depth ----_--------------- Diameter-'-----............. Number ---------------- ---------- Rock Filled Yes ❑ No .❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well --------------------------------- Foundation -------------------- Prop. Line --------------_--.-- REPAIR/ADDITION(Prev. Sanitation Permit# ---------,---"---------------------------- Date -------•-------------------•------1 7 Septic Tank (Specify Requirements) •__,'__ _r Dis osal Field S ecif Requirements) - - -- �.• I rte_ � +- -------- - ---------+ --------- Y- O • 11 -----------------s 1. __________________________________________________________________ (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 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------- I---- -- �r ----- Owner BY ---------------'----=- 'T- Title " p--------------------- ---------------- (If other than owner] r,EOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------------------------------ --------=----------------- DATE _.- ."- I----�-----'-------------- BUILDING PERMIT ISSUED ---------- ---- ---j_DATE -- ------ ADDITIONALCOMMENTS ----------- ------------- -----------------'-------------------------------------------------- ------------ - ------ ----------•---------------- 0 "..T ---------------------------------------------------------'=----------------- ----- .------- ---------------------------------------------- -- z ------------ ---------------------- ------- -----------------------�;---------- = ___ Final Inspection b = ----------------------------------------- ------Date .�� - ---------- p Y t SAN. JOAQUIN LOCAL HEALTH~DISTRICT,. E. H. 9 1-'6$ Rev. 5M