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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT PX4 -- --- ----------------- -- ---------------------------- Permit No. 16 (Complete in Triplicate) . _ __.__ _ ----- ------------------------------------------------------____ This Permit Expires 1 Year From Date Issued Date Issued 5:)3-2/_.. 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/LOC ON "rJ��C� �r ` ` �i�r�`. ---------------------- --------------------CENSUS TRACT Owner's Name - �✓_ 6.� Ph e----------- ---------------------City - -------- Address --------_-� � '--------------•--------- Contractor's Name ___ License # � 3 _ Phone _____________________________ Installation will.serve: Residence Apartment Housef] Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units:-.---. --_ 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 •K Clay Loam C Hardpan E] 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 ____---_--_-______________ d Capacity -- ----------------- Type ------------------- Material---------------------- No. Compartments -.-------------------- Distance to nearest: Well ---________________________________Foundation ---------------------- Prop. Line ---------------_______ Q LEACHING LINE [ ] No. of Lines ___________ ____________ Length of each line----------------------------- Total Length --------------------------- --------Depth Filter Material -------------------------------------------- 'D' Box __._______ _ Type Filter Material ___.._____.. Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line_ _-__-__-_--_-__-__-_____ SEEPAGE PIT [ ] Depth __________________ Diameter ---------------- Number ---------------- -- Rock Filled Yes ❑ No :C] WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation ---------------__-- Prop. Line ------------- ------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------_--------------------) SepticTank (Specify Requirements) ------------------------------------------------------------------- ------------------------- ---------------------------------------------- Disposal Field (Specify Requirements) ____ -C - C`_ s?___-P-� __ G� L -----bpo._r_- Yom- i L i --«9►.-u------------------------------------ -----------------------------------•------------------------- ---------------------------------------------- -------------------------------------------------------- - - - - (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 ----------------- '------------------- Owner -- -------- --- By F .°� Title �J (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY s.. , ---------------------------------------------------- DATE .__SLQ'_?- BUILDING PERMIT ISSUED ------------------------------------------------------------- -- --- ---DATE ------------------------------------------- ADDITIONAL ----------------------------------- -- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------=--------------- r I -- ------------------------------------- ---------------- --- -----------^----- -------- -------- ---------------------------------------------`�-��- - - - ----- a nspection by: '�� Date Fin f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b13 Rev. 5M.