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FOR OFFICE USE: " ;PPLICATION FOR SANITATION PERMIT Jam'----------- --------------------------- �U / (Complete in Triplicate) Permit No. ' .- s Date Issued `1 This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein pp p County Ordin nce No. 549 and existing Rules and Regulations: described. This application is made in compliance with JOB ADDRESS/LOCAILO�1 . �/ --��"----.-5 ' -- 'S------------- --------CENSUS TRACT �;: Owner's Named �) Q Phone g __- Address ------ - --- - - - ------------- Contractor's - ------------------ Cit s Contractor's Name � � 1 �Y -- License # F %hong/�-= "� -- -- -� --- / Installation will serve: ResidencAe Apartment House❑ Commercial ❑Trailer Court i❑ MoOther -------------------------------------------- Number of living units:____ Number of bedro s _ _____ rbage GriOdder Lot Size p___ ' � ��e� Private Water Supply: Public System and name __________ _ _ _ _ _ ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ AdobeFill 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 se page pit permitted if public sewer is available within 200 feet,) /- PACKAGE TREATMENT [ ] SEPTIC TANK iz __ ___ ._ _ _____ Liquid Depth __ _. .. _v .. . Capacity _`_,.__ Type - __ Material a►*?__ No. Compartments __ _________ _______ Distance to neares : Well _________________________________-Foundation /�------------ Prop. Line�.__�_....___ Q LEACHING LINE No. of Lines ---_- -------__---- Length of each line________ --------- Total Length ,_,_... ............. D' Box � f _______ r ...... ..............------ Type Filter Material Distance to nearest: Well ___-_r1`______ Foundation ____ ___e�_.�_____ Property Line .-� _____-.-. _- SEEPAGE PIT Depth � --- _____ Diameter��rr _� _.____ Number _______ _________________ Rock Filled Ye _ No Water Table Depth ----------46,f---------____________________Rock Size _�__ L__` /_....____ ---Foundation _____ _/_ �___ Pro l.._._...____ Distance to nearest: Well ______________'____ ___._______,. 1 p• Line REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------------- --------------------- ----------------------------•---------------------------- DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------•--------------------- --- ------------------------------------------------ ------- ------------------------------------------------------------------------------- ------------------------------------------------------------- ------------------- ----------------------- ------------------------------------- -_ -----------7--------------------------------------------------------------------------- (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 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: "1 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 Eofifornia." Signed --------- -- ------- - ----------- Owner BY ------- -------- >. / -- ----- ----- Title ' --------- ----------- --- er t an ner OR DEPARTMENT USE ONLY APPLICATI N ACCEPTED BY _- - ---------- DATE `- S,c C�'------"`. : BUILDING PERMIT ISSUED .- ---- - - ---------------------- `� - .ham.. DATE ----- - - ADDITIONAL COMMENTS _____________ --------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ------------------ --------------------------------------------------'-------------------------------------------------------------------------------------------------------- ------------------- ------- ---------- --- �y� -- -- - ---- Final Inspection by: -- � - Date _ �� c` ➢'3 SAN J AQUIN LOCAL HEALTH DISTRICT / E. H. 9 .L-'68 Rev:5M -