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d FOR OFFICE USE: APPUCiTION FOR SANITATION PERMIT ------ Permit No. r- (Complete in Triplicate) V Uzi ---------------------- Date Issued -- ------ -- -- --- ------------- 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 described. This application is made in compliance with County Ordina a No. 549 and existing Rules and Regulations: -- 1� _ JOB ADDRESS/LOCATIO ___CENSUS TRACT _._______________________ --- -- - ------ -- --- - Owner's Name ---------- ------- --------------- ------ ---?-------- Phone 9, 1-� ` 0 Address -------------`--------------- --------------- -- City __ - --- ---- ------------------------------ -------- --- ---- -- ------- ------ ------ Contractor's Name ------------ ---- ---------.License ---------------------- Phone InstaII&i*n wHI-serve Residence `Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:---!------- Number of bedrooms _-_2.o%:G0'rbage Grinder _,j.._ Lot Size --- `_ Water Supply: Public System and name ----------------------------------------- -----------------------------------1------------------------------Private f , ` Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam-C] Clay Loam ❑ Hardpan ❑ Adobe Fill Material _____t___ If yes,type _-________________________ f (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,) PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------------------- Liquid Depth __-_____-_._-___-,_-_ Capacity ---- ------. Type -------------------- -- ---- ------ Material- ------------ No. Compartments ----- -- --------- Di3tance to nearest: Well ------------------------------------Foundation _________________-__ Prop. Line -__-_____.._____---.-- LEACHING LINE [ ] No. of Lines ---- Lengthy of each line--------------------- _____ Total Length ------------........._...... 'D' Box _________ Type Filter Material --------------------,Depth Filter Material -------------------------------------------- Distance _______________________________ _________ Distance to nearest: Well _______-____---_-_-___ Foundation ____________________-__ Property Line ___-___....___..._._.... SEEPAGE PIT [ ] Depth _________________ Diameter __.-___-____- Number _______________.________._ Rock Filled Yes ❑ No Water Table Depth ---------------------- -------------------------Rock Size Distance to nearest: Well _-________________---_____-___-_--_-_-Foundation- ._-_____._-___-__- Prop. Line ____._..__..........-. REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------- -------- Date __-____----____-__-__.____________) t Septic Tank (Specify Requirements) ----------------------------- ---------------------1--------- ---------- ------- ------ - Disposal 'eld (Specify Requirements) ---- ------------- - --------7_0-)-- ---_------1---------------' ----- ' --- (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -- ------------------------------------ Owner BYTitle -- -- - ------------------------------------------------ ------------------------ an owner) oel FO DEPA TMENT USE ONLY oal- APPLICATION ACCEPTED BY DATE ----- S•"'/%t,'�s� BUILDINGPERMIT ISSUED -------------------------- ----------------------------------------------------------------------------DATE ------------- ---------------------------- ADDITIONAL COMMENTS---------------- -- --------- ------------------- -------------------------------------------- -- ------- ----------------------------------------------------------- - - - ---------- c� -------------------------- ------------------------------------------- -------------------- ---- ---------------------------------------------------- -------------------- -------------------------------------------------------------- -- f Inspection bY: ---- ------ ---------------------------------------------------------------------Date !L _�_P -------L-- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M