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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. --- -- --- -------------------------------------------------- p' 1 Year From Date Issued Date Issued This Permit Expires AVIJ far 9-2_1O-zg le 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 ADDRESSAOCATI_ wN ___.G---- -- - --- --------- �'-- - --- ---- -- - -- --- ----- 1_.------CENSUS TRACT --:----------------------- Owner's Name --.$--------------------- ------------------------ --Phos - --- - -----------------------•- Address ---- � "Eht -_------ _ lh -- � CitY --------------------- Contractor's Name ---- , - -- „_e�License # ---�D_f JV> Phone - ---------------------------- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court !❑ Motel ❑Other --------_/----- ---------------------------- Number of living units:----/_-__ Number of bedrooms ------T_--Garbage Grinder ... Lot Size __-______________________________________ Water Supply: Public System and name ------As— Private ❑ Character of soil to a depth of 3 feet: Sand'❑. Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ ,;x Hardpan ❑ Adobe ❑' Fill-Material ------- If If yes, type ------------__-_-----_- n DIP (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r PACKAGE TREATMENT { J SEPTIC TANK'[ Size-(/ ---IKS------------------ Liquid Depth 9__________________,____ 1 + Capacityrt Type _ _ _ ___ Material_ s� No. Compartments __S�+ ------- ..._. Distance to WeareWell ____......_______________ .Foundation --___I_r7---- ------- Prop. Line LEACHING LINE No, of Lines _-_____.1____--_____ g ___ Length of each line-----------ry._10..._-------- Total Length -_%-4)____________________ 'D' Box ---W--- Type Filter Material ---_S_- --------Depth Filter Material -If-------------------------------------- e__ - ---------------------------------- pistance to nearest: Well _____- a_e__?`'__ Foundation _._-_._I_D_�_____-__ Property Line p tY z. �' [ ] Depth ------1-$---------- Domer ----X__�-�_-- Number -----------/----------- -- Rock Filled Yes #� No ❑ Water Table Depth ---------------H)0--------------------------Rock Size ---------- ,4 Distance to nearest: Well ----------/10 0------74-----------._Foundation ---1_q----------- Prop. Line ...s---------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ Date ----------------------------------) Septic Tank (Specify Requirements) ---- --------------------------------------------------------------------------------------- - Disposal Field (Specify Requirements) ----------- ------------------------------------------------------------ -----•----------- ---------- -- -- --- ---------------------------------------------------=------------------------ -------------------------- ---- --------------------------------------- (Draw a sting Vd required 4ddition on 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." SignedOwner By ------ ---- - - 4- Title - --------------------------------- Q_- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------ -- � ------------------------------------ DATE ~`�-77� ----------------- - BUILDING PERMIT ISSUED - ------------------------- ------------DATE ------------------------------------------- ADDITIONAL ------------------------------------ -- - -- --------------------------------------------------------------- - ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- ----------- --------------- ------ - ------------------------------------------------------------------------------------------------------------ Date --f!. Final Inspection by: --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M