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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT Permit No- ------------ (Complete -----(Complete in Triplicate) �i - Date Issued -------- ---------� This Permit Expires 1 Year From Date 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: f JOB ADDRESS/LOCATION . wjq� rS Ti � ---------- --CENSUS TRACT -------------- ----------- Owner's Name -------0s----- --------------------------------- ----------------------------------------- --------Phone ---------------------_------------- Address ---- --_----- ------------------- CitY ------------------------------ ------------- Contractor's Name ---le , - ---------------------------------------License # ---------:-------------- Phone ------------------------------ Installation will serve: Residence$Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑ Other --- - ------------------------------------- Number of living units.----/---- Number of bedrooms ------Garbage Grinder - _ Lot Size ;w-- Water Supply: Public System and name -_ - if __.. �� --- $ -----------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ,C] Clay Loam 0 Hardpan ❑ Adobe)9 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,J PACKAGE TREATMENT [ ] SEPTIC TANK Size-- - -A--Jf---------- ------------ Liquid Depth ' ------------------ 1Z\1 + Capacity AZO-99------ Type �; AMateriol-Alg7W-0,-�---- No. Compartments ---�._---=---- Distance to nearest: Well --____T-----------------------Foundation - -_,_--__-___.Prop. Line _> _.. -.---•-- LEACHING LINE No. of Lines ----/---------------- Length of each line---- f- ------ Total Length _-- ..-_-____...._._. 'D' Box _- Type Filter Material/ fe* Depth Filter Material __________________________________ Distance to nearest: Well --------------------- -- Foundation -------- Property Line _-/ ----...... -- SEEPAGE PIT [)fJ Depth --at�------ Diameter -_-___ Number _----�---- -------------- Rock Filled Yeses No i❑ Water Table Depth ---Ko----------------------------------Rock Size/------- ,;F- ----------- Distance to nearest: Well -- r-- -----------------------Foundation _PG9---------- Prop. Line ---------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------11 Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ------------------------------ Field (Specify Requirements) -------- -------------------- ----------------------------------------------------------------------------- -- € ----------------------------------- ---------------------••- --------------- -- - ---- - - ----------------------------------------------------------------------- ---------------------------- -•----- {Draw existing and required addition an reverse side) I hereby certify that 1 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 ' Title --- z.�� n. (If of than owner) FOR DEPARTMENT USE ONLY ff1 APPLICATION ACCEPTED BY ---�--P--�---- - -0 -��-={�----------------------------- -- ------------------- DATE _� --- --6_- i BUILDING PERMIT ISSUED ------------------------------------ --------- ------------------------------DATE - ---------- ADDITIONAL COMMENTS -------------- -------------------- --------------- --___-- 74-i .o- --------------------------------------------- ------------ 1 Final Inspection y: - - Date �,V- �. SAN JOA UIN LOCAL HEALTH DISTRICT ' E. H. 9 1-'68 Rev. 5M; �