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FOR OFFICE USE: FAPPLICATION FOR SANITATION pERMiTPermit No. _ ' -------�------------------------------------------------- - (Complete in Trip irate------------------------------------------ Date Issued-- This Permit Expires 1 Year From Date Issued --------- - - truct and e work rein o cons Application is hereby made�to ad Son complin Locce al Health District for ounty ordinance permit t and existing RulestalndhRegulations- described. egulat ons- described. This application 33 C _( ( -_ - -------t�C/- ---------------CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION ....---------- -----------`-- Phone Owner's Name - - - 19 Address ------------------ City ----------------- ----- --------- ----------------------------- ------------------------------ _ . --------------------------------------- -------License # .��7 - - Phone ------------•--------• ------- Contractor's Nam . -----�---7- Installation will serve: Residence [� Apartment Ho use❑ Commercial Trailer Court ❑ Motel ❑Other --------------------------------------d---- .---- Lot [ � l Number of living units ------ Number of bedrooms -----Garbage Griner __ fl--- --------Private Private Water Supply: Public System and name ---------------------------------•-- ------ -------- ---- Character of soil to a depth of 3 feet: Sand' i!t C1Clay ❑ Peat El Loam ❑ Clay Loam E] ,. Hardpan F1 Adobe E] Fill Material ------------ If Yes, type ---------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) 0 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ------- I PACKAGE TREATMENT [ ]' SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -------------------- W -.___ No. Compartments -----------------=---- (�} Capacity - Type -------------------- Material---- ------ - p Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ____..- -_----------- �! _.___ Total Length _ Len Length of each line----------- ---- ---- ----------------------- LEACHING LINE ( I No. of Lines g ---------------- - - l 'D' Box ___ _______ Type Filter Material __________________ Depth_ Filter Material --------------------------------------- 1- Distance to nearest: Well .................. ..... Foundation _-..-------- Property Line ------------------------ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ..-------------------------- Rock Filled Yes ❑ No 0 Water Table Depth Rock Size---..--------------------- r� ----------- Prop. Line ----- ---------------- Distance to nearest: Well --------------------------------- ------------_.____._- ' REPAIR/ADDITION(Prev. Sanitation.Permit# -------- ----------- Date ----------------------------------1 ------ S Septic Tank (Specify Requirements) ------------------------------------------------------- [ - - ---=---- ---------------------------- -- -a_� Disposal Field (Specify Requirements) --------------- ------------------------------- -------------------------- -------------------------------------------- ------- ---- -- - - -------------- (Draw existing and required addition on-reverse si e) I hereby certify that I have prepared this application and that the work will,be done in accordance with San Joasluin 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 - -------- ----------- ------- (if other than owned FOR DEPARTMENT USE ONLY q _________________ DATE = ' _ APPLICATION ACCEPTED BY _ --mar-- --- - -------- ------.--- - ----------------------- -- BUILDING PERMIT ISSUED ------------------------ - ---------------------------------------- -------------- ADDITIONAL .--------ADDITIONAL COMMENTS -------------------- --------------------------------------------- ----- ----------------------- ----- ---------------------------- --- ------ -- ------- - --- ---------- -------------------------- ------- .------- ------ ------------------------------ __ __ ----- - -- - - -- - ------- ,Date ------ - Final Inspection by: -------------- ----------------------- - ------------ ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M y