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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------ (Complete in Triplicate) ------------------------- ----------------------------- Date Issued _.�-�'�-- =-7---• This Permit Expires 11 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: yv ------------------CENSUS TRA __ '_-` JOB ADDRESS/LOCATION _ - -�- -------/1-....... Owner's Name ----- ------ Phone - ----- ---------------------------------------- -- ------------- Address _ L -----� ----------- City -- -- -- ----------- -----•----------------•---------------•--- ••---- --- -- ----------- --------- Contractor's Name _.. ._ — License # _� -y--- Phone ------------------------------ /' ' "` ''- ----- ---------- - -------- - Installation will serve: Residence Z.partment House f-] Commercial :❑Trailer Court ❑ I Motel ❑ Other ------------------------------------------- -------------------•----- Number of living units ----- Number of bedrooms _�____-.Garbage Grinder ------------ Lot Size ------- _ _�-i-�� Water Supply: Public System and name -------------------------- ------------- ---------------------------- ---•• Private [ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan d Adobe ❑ Fill Material ------------ If yes,type ---------------------------- t (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 [i�-�" � Size /,� S ___-------- Liquid Depth __.___ _._____.___._..-- �` f Capacity Type �ONo. Compartments Distance to near st: Well ----------1`u-------------------Foundation ------fir"--*----- Prop. Line -----_ _-- --.---- LEACHING LINE [P( No. of Lines ----- �i __.___.__ Length of each line____-__Ll,_Q_f___.__ Total {Length ,__ f' :---.•. 'D' Box --__ _._ Type Filter Material _ --_1 --------Depth Filter Material _J_ ------------------------------------- Distance to nearest: Well ------_50- ....... foundation -r------D------------ Property Line -- --------- i -------De Depth ___ _ -�__-- Diameter __3.3_�t___ Number __.___ --______ ---- Rock Filled Yes,( SEEPAGE PIT p ,.No . 't Via..! ___ �.� ' Water Table Depth '- Rock Size _____ ________X_____•--____-- * j Distance to nearest: Well ------`-----• --------------------•-----------Foundation '---1-0--------- Prop. Line ............. REPAIR/ADDITION(Prev. Sanitation Permit# ----•--•------------------------- -------- - date ---------------------------------- Septic-Tank! ____-_____-----------------------Septic-Tank!(Specify Requirements} -------------------.-------------------- - ---_----------..__,,.---------------_--------.-- - Disposal Field '(Specify Requirements) --------------------------- -------------------`---------------- k t ________________________________ _ .. ._________---____ ___._.-__ __------------------------------------------------ _______-_____-_____--_________.._______________-____________---__.___-.-_____ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin k. 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." Owner Signed Signed --------------------------------- - ------- By ----- ---- ------------ Title ------ ---------- --------------------------- (If other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ------ ---- - - ---- - -------------------------------------------------------------------. DATE _- :::? .-------------------- BUILDING PERMIT ISSUED ----------------- DATE ----------------------------- ---------------- i ADDITIONAL COMMENTS ----------------------- --------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ------------------------------------------------------------------------------------------------------- -------------------------------------- ------ 71 Final Inspection by: __ . _ __.___Date /�---7`---------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. SM