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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------------%-------------------- (Complete in Trlp�eate) Permit No. --------- -'3 Date Issued :_ :_ _________________________________ t ---------- 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION 44 S. _Gti`___ I Urv _________CENSUS TRACT _________________________ Owner's Name / C a �= C'e+-� ----------------------------------------- Phone ----------- Address ------------------------------------------ ---- --. City ��I/�i ----------------- ------------------------------ �/ /- C f / Contractor's Name _ ____t� _.___�6I _ /_ ___.____.._------------------------License # l__________ Phone -_ �.�'...�� Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court Motel ❑Other ----- -------------------------------------- Number of living units:---- Number of bedrooms __ ----Garbage Grinder __________ Lot Size _____________ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand 0 Silt L7 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 is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size___ C`>_X _� f�__ ,___ Liquid Depth .......... Capacity /__ -C�__«_ Type { " 4_ Material__. `G' t!4-__ f4 o. Compartments - --------------=---- Distance to nearest: Well ____ '_____________________Foundation __/__G�_--__--___ Prop. Line - ------------ --- C LEACHING LINE [ ] No. of Lines -___s3_____________ Length of each line----�__(-------------- Total Length c,2/..0_________________ 'D' Box ___ ------ Type Filter Material _ �"�z`_=Depth Filter Material ,lam 1._______.___.................... i Distance to nearest: Well ------t7__------ Foundation -------- C_'________ Property Line -,I) .............. 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 ----------------------------------) SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------•---------------------------- DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 become subject to Workman's Compensation laws of California." Signed -------------------- Owner �- By ------- -`= ----------------- ------------------- Title ------------------------------------- ---------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ,p- -- - - - DATE /, BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------- --------------------DATE ----- ------------------------------------.. ADDITIONALCOMMENTS _.----------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ___________________________________________________ _ _ _ , _3-____-______-___-_-___-_-_________-__-____._______-_-___ - Final Final Inspection by ----------------------------- --------------------- ---------------Date --- 'l7�-� ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M