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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} Permit No: --------------- 'this Permit Expires 1 Year From Date Issued Date Issued-3_':_7 f Application is hereby made to the San Joaquin local Health District for a permit to construct and install the wont herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION -AV ------------------------- TRACT ------------------ Owner's Name � ------ f -- •- -------------- - --------------------- - -------------- --------------------------Phone ------------ Address _21'e-y , -•�T 4 d,vOg i . Contractor's Name .- y��"s ---------------------- -------- Phone ------- ---------------- ------License # ------- ---- Installation will serve: Residence E]Apartment House�[] Commercial ❑Trailer t j Motel ❑Other ----------- ------------------------------- Number of living units:---I------- Number of bedrooms _;--------Garbage Grinder --.------_-- Lot Size --------------------- --- F Water Supply: Public System and name --------- --------------------------------------------------------_---_---------------- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .Pr Clay Loam Hardpan ❑ Adobe '❑ 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.) Dr NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK"" ------------ Liquid Depth •--------. Capacity -ZAa-D- Type - --- Material--�/_ No. Compartments _.;�------------ ---- l Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------------ LEACHING LINE LINE J? No. of Lines -.�-----------.----- Length of each line___,,P0-------__-.-_--- Total Length .--------------- 'D' Box•Gt!?^tXq. ype Filter Material --_Depth Filter Material 1O__-!---------------------------------- Distance to nearest: Well ------------------------- Foundation ----------.------------- Property Line- -- --------------------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ Water Table Depth ------------------------------------------------Rock Size ------ ------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# --------------_-----------______-----.--- Date --_---------__-------------------) t, SepticTank (Specify Requirements) -------- ---------- ------------------------------------------------------------------------------------------•.---------------------------- Disposal Field (Specify Requirements) ---------------------------------------------------------------------------------------- --------------------------------- ---------- ------------------------ ----------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I 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 b me.subject to Workman's Compensation laws of California." Signed `---- ------------------------------------ Owner By - ----- ----- ---------------- -- ---------------------- Title ----------------- ------------------- ----------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------- ------------------------- - ---------- . DATE '/T..�� -------------- BUILDINGPERMIT ISSUED ------- - ---------- -------------------------------------- --------------------------------------------DATE ------------------------------------------- ADDITlONAL--COMMENTS----------- ------------------------------------ -------- ----------------------------------- --------------------------- -------------- -- --------- --------------- ------------ ---- ------ ---- ----------- ---- ---- --------------- ------------------ --- -------------------- -- -- ------------- --- ------------ __Final - Inspection by: , -- -. - Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M