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• f I:. a A - FOR OFFICE•US -' APPLICATION FOR.SANITATION PERMIT _ Permit No.. ------- --Z-------------------- 3 't (Complete in Triplicate) ------------------------------------- Z .Date Issued ___._'---------- ___.. This Permit Expires 1 Year From Date Issued --------------- Application is hereby made to the,San Joaquin Local Health District for a per 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 -----------------------------------------------'2f` v --- - -----CENSUS TRACT _ --- --------- f� /i �' ' Owner's Name _ �,� / Phone ! a ------C-- city 0/ ---------•-••--•--- Z �' �?_�� r -'--1;2 E �� License #Z , l Phone = Address . . Contractor's Name .7'_ 7 k Installation will serve: Residence � partment House❑ Commercial:❑Trailer Court l❑ N Motel ❑Other -------------------------------------------- Number of living units:-.-_ umber of bedrooms -------Garbage Grinder _�__ __ f5 Lot Size ----------------- •----------------•------- Water Supply: Public System and name ____________________ Private ❑� - Character of soil to a depth of 3 feet: Sand'[� Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan E!i' Adobe ❑ Fill Material ------------ If yes, type ---------------------------- } 4 E (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) k NEW INSTALLATION: {No septic Itank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------- -- ------ Liquid Depth -- ------------------ ----- No. CompartmentsCapacity ------------- Type ______________ Material_________.__--- ----- i Distanceto nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- --•---- LEACHING LINE [ ] No, of Lines ____ ----______ __ Length of each line---------------------------- Total Length -_____-______-----___________ 'D' Box - ------ Type Filter Material --------------------Depth Filter Material --------------------•----------•------------� x Distance'to nearest: Well ________________________ Foundation _ Property Line ________-___-------:---- rn SEEPAGE PIT [ ] Depth --- ---------------- Diameter ____----________ Number .--____-__----_______------ Rock Filled Yes ❑ No i❑ Water Table Depth Rock Size ____.____________ ------------ i i ___ __.____Foundation p• • Distance to nearest: Well ------------------------------ -------------------- Pro Line --------•------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------•--------------1 ' Septic Tank (Specify Requirements) -------- ---�--- ®� --------------------------------------------•-------------------------.----------- Disposal Field (Specify Requirements) r ".` -� / ' ----------------------------------- -------------- ---------=--------------- --------------- ----- ----------------------------- -_- --------------- ----------------------------------------------------------------------------- (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 Mules and Regulations of the San Joaquin Local Health District. Dome 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." 1 Signed --- ----------------- Owner ------- Title - ------------ - By E - (If other# an o r) FOR DEPARTMENT USE ONLY k APPLICATION ACCEPTED BY ----=-------- =- --�- ---- ------------------------------------------------------I------ DATE ------ -�_ '" ------------- ' BUILDING PERMIT ISSUED -------- I----------- --------------------- ----DATE -- ---------------------------------------- ADDITIONALCOMMENTS ---------- ------------- --------------------------------------•------------------------------,- - -------------------------------=--------------------------- - ------------- --------------------------- ----------=----------------------- -------------------------------------------------------- - Date ---------- -------- Final Inspection by: ------------------ -- ------ ------- ----------------------------------------- SAN 'JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M