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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 --s- .` 7 Application is hereby made to the San Joaquin Local Health District for al 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 1_S _ ----------- �-- --CENSUS TRACT -------------------------- -----.-- - Owner's Name C. --- - - ----------------------------------------------------------F-------------------Phone �_S�_' 6�7 ---•---- r� ------- { Address _? T --------------- City -u < - Contractor's Name ------------------------------ ---w---��-------------- -------.License # J_._ . Phone 6_`9 � -------- Installation will serve: Residence [XApartment House❑ Commercial :❑Trailer Court ;I❑ Motel ❑ Other -------------------------------------------- Number of living units:--------{__ Number of bedrooms -_____Garbage Grinder ------------ Lot Size ----Z___ � _.-__...._,_ Water Supply: Public System and name - - Private Character of soil to a depth of 3 feet: Sand'❑ Siltj] Clay ❑ Peat ❑ Sandy Loam ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer i3 available within 200 feet,) PACKAGE TREATMENT Ca acEP1C TANK Size__:-_____. S -_-------_•-__ Liquid Depth . - � P YYpe � fierial- -��4ylG No-f Compartments ------ •-----• V' Distance to nearest: Well _-------� -__*_____---------Foundation ----1_D___________ Prop. Line _-57_1`_._..... sN LEACHING LINE , No. of Lines ___-_---�'--___._ Length^o Bch l- Total Length __�___.___ N D' Box __[ ._ Type Filter Mdterial` ----Depth Filter Material _____ -�r__ __________________________ - �* c r SEEPAGE P,' Distance to�eare/st; Well _ _,�______--- Foundation�.C_8___'+�.__I__ Property Lin __.r-_ `__._.... m [d] Depth __ ._�__ ----- Diameter _3.3________ Number -- ---------------------- -_ Rock Filled Yes No � , 1T, . Water Table,Depth `r_, �'„�a •------- i ----- �` _ _ _---Rock Size -----1-�.+-�_1- m ' �� -----Foundation -------- ----- Pro Line ---------------------- D istance._to.-ntecirest: Wel -___-__________ _ -_ - REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date --------------------- ------------- Septic -_--------_ Se tic Tank (Specify Re uirerri ---------------- } Ifents1 ----- Disposal Field (S eci f7-ReL+vire a ts) ------- ------� '� ------------------- ---- I t � P Y q �••-- , =---r -- � ,... ,r - -------------- t (Draw existing and required addition on reverse side) I hereby certify thatnhave prepdred this application and that the work will be done in accordance with San Joaquin! County Ordinances, State Laws,Jand Rules and liegulations of the San Joaquin Local Health District. Homo owner or licen- sed agents signature certifies the following: "I certify that in the performance ofrthe work for which fhis permit:is issued;t shall"not employ any person in such manner as to become subiect to:Workman's Comp#ensation laws of California." Signed ------------- ---------- --J ------- l----- -------------------------------- Owner BY ------------- ---- -- --- �� - -- ------------------------------------ Title ------- - RT other an owner)� FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY ------------ DATE ----- _-�- _-- _-- - ------- ------- BUILDING PERMIT ISSUED ----------------------- DATE ADDITIONAL COMMENTS --------------------- -------------•----------------------------- ----I-------------------------------- --------------- ------------ --------------------------------------------------- ------------------------------------------------- -------------------------- r � Y .� .; ; ----- --------------- Final Inspection by: _.--------------------------------------------------------------------------- -Date --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, 9 1268 Rev.-5M .�