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FOR OFFICE USE: a - „ APPLICATION"FOR-SANIYAYION PERMIT �� v� - ` � •9 Permit No,.(Complete in Triplicate) -"- , - ---------------------------------------------------------- -----------------_---------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -- --71--. 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/LOCATION .-----T - - , 1 ____ ----- - __ JOB TRACT -------------------------- Owner's Name ........ ------- - ---------------- --•---.——------------------------------------------ --------Phone `T�?3�.��-.._.. Address ----------- --------�i -�f _ 1----------- --- -- -- - ------- ._:_. City i ---- --------------------------------------------- Contractor's Name --____-__------ - _ - -------- -.- --_ -------------License #IlrL?.�--- Phone Installation will serve: Residence ❑Apartment House,❑ Commercial :❑Trailer Court ;❑ Motel ❑Other -------4)------ ------------ -------- f Number of living units:----7)�Number of bedrooms ____;2'--�Garbage Grinder ------------ Lot Size __ ____x _________________ Water Supply: Public System and name ---------------------- ----------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 'D Hardpan ❑ Adobe'Q Fill Material ------------ If yes,type -____---__--------------- r ky (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,) S PACKAGE TREATMENT [ SEPTIC TANK'[ ] Size---------------------------------------------r Liquid Depth ---------------------...... Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------------ IJP Distance to nearest: Well __________________________________Foundation ---------------------- Prop. Line _____________:- LEACHING LINE [ ] No, of Lines ------------------------ Length of each line---------------------------- Total Length ---._--____-______. -. --_-- d 'D' Box ----------.- Type Filter Material --------------------Depth Filter Material --------------------•-------------I—...... Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line _____-____----___--. -__ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ----------Rock Size -------------------------------- Distance to nearest: Well ---------------------------------- -----Foundation --------- ----------- Prop. Line .... -------------- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) -------------------------------- --------------------------------------- --------- Disposal Field (Specify Requirements) ------------ i __.-. �L�----- - --�5 ,- �-.moo - - ----- -- --- -- --- ---- - ---�fi�'r-:--cam'- --.��- --------- -- -- - ---- --� -�-- (Draw existing and required addition on reverse side} k I hereby certify that I have prepared this application and that the work will be done in "accordance with Sam 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 --------------------------------------- -- -- (If By -------------------- --------------- Title '-----. . --- -------------------------- - ------- ---------------------------- ------- - ot than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY I— _ DATE � � BUILDING PERMIT ISSUED --- DATE ADDITION - ----------- AL COMMENTS - -------------------------------------------------------- --- - ---------------------------------------------------------------- - ------------------------- --------------------------------------------------- --------------- - - - -------------------------------------------------------------------------------------------------------------- ----- __ - - - - - - - - - - - - - - - Final Inspection by: - ------------------ ----------------------- --Date -�[f� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M