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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -Permit No. �p_ 3/� ------------------------------------------ -------------- -------------------- [Complete in Triplicate) Date Issued ---------- - -- This Permit Expires I Year From bate 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. 549 and existing Rules and Regulations: --------CENSUS TRACT --------------•--•-------- JOB ADDRESS/LOCATION ------ - L I r Ph o --------------------- Owner's Name 'r --- - -- ---- -- -- Address ------------ -4 - City r f ' - License # _l -a� Phone ------------------------------ Contractor's Name __._-____ Installafion will serve: Residence )kpa ent House❑ Commercial :❑Trailer Court C] Motel ❑Other ------------------------------------------ Number of living units:._._ "__. Number of bedrooms 3-------Garbage Grinder ------------ Lot Size _-- --------- •------ Water Su 1 Public S stem and name --___---_____ Private ----------------- Character of soil to a deptJof 3 feet: 'Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam o w Hardpan ❑ Adobe ❑ Fill Material ----- ------ if yes, type ---------------------------- - 1� - '--'" " buildings, etc. must be placed on reverse side.) 0► (Plot plan, showing size off.lot, location of system in relation to wells, NEW INSTALLATION:; (Ni` septic tank or seri age pit-permitted if public bliic sewer is available within 200 feet,) SEPTIC TANK X. __ Liquid Depth ------------•-----•----- ETREATMENT [ ) [ i Size �-----X -fir--- - ` PACKAGE C parity _�2+��?__- --- Type c _ Material__ --- No. Compartments ------�... . I t :.� 1 Foundation ----� �- ---- --- Pro Line --_--- ---- Distance to nearest: Well -----------_-_- -0-----_------ P LEACHING LINE [ No. of Lines ------- Y Length -of each lineF -___. �-------- Total Length --------------------•- - - 10- -' ' ____.De th Filter Material ___- - r 'D' Box ---- " ----_ Type Filter Material --_- -'��- P ( iM + (2 L-------- Property Line --G� ----------- Di� y. stance t nearest: Well'_.__---- e)_--"____ Foundation ____ nrl7GM [� Depth ------- V ""-- D�aae#ef X Number ------ -r-�- Rock Filled Yes No Water Table-Depth- ------------------v�`Sr Rock'Size ---I--------� ----- --------- 1 I W - --•---- -. p _ �'D rProp. Line . fi Distance to nearest: Well _______`:~___________________________ Foundation 11 4t� REPAIR/ADDITION(Prev. Sanitation Permit# -------=------------------------- ------- ----�-- Date ----------------------------------) I --- ------ ----------- Septic Tank (Specify Requirements) ----------------------- -------------------------------------- Disposal Field (Specify Requiremenfis) -------- ------------------•---------------- ---------- -----------:-_ ---------- ------------------- ---------------------- --------- t I (Draw existing and required addition on reverse side) I hereby certify that I hate prepared this application and that the work will be done in accordance with Sats Joaquin County Ordinances, State ILaws, 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 beiome subject to Workman' !,pensation law f California." Signed ---------------- �� ---- ----- - Owner ---------- r t I e ---- ---------- 1 (If other thahn owner) I� FOR DEPARTMENT USE ONLY APPLICATION�ACCEPTED:l B ------- ---- --------------"------------- DATE �/7 0 - ----------------------------------------- - BUILDINGPERMIT ISSUED --- --------------- ----------------------------------------- --------------DATE ( ADDITIONAL COMMENTS ------------------------ -------------------------------------------------------------------------------------------------------------------- - [ i ----------------------------- ---- ------------------------------------- ------ ----------------- -------------------------------- ------------------------------- __ =--k "------ -- -------- --- ----------------------------------------------------------------------- ----------- ,,,.te�ee ,� -11-0- Final Inspection by: _ -------- ------ -------•------------------------------- -Dafie ' F SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'613 Rev. 5M