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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y ----------- ----------------------------------------- (Complete in Triplicate) Permit No. (�__---_---- --------------------------- This Permit Expires 1 Year From Date Issued 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 ADDRESSAOCATION ---- - - CENSUS TRACT ---------- -------------- Owner's Name --------C�/ • ---------- --- -------------------- ---------------- --- - ----------Phon�---------- ----------------------- Address ---- --------- �.� v �r E f ��/ ------ Contractor's Name _._ _` -------_________________ ___ -------.License # -_ ;_�16 Phone Installation will serve: Residence partment House❑ Commercial :❑Trailer Court !❑ Motel ❑ Other -------------- -------------------------- Number of living units-----/----- Number of bedrooms ---,..--.Garbage Grinder ---IkO_ Lot Size .-14009 '- KVZ_V_T------ Water Supply: Public System and name ---------------------- ------------------ -------------------------•------------------------------------------Private R;-- Character of soil to a depth of 3'feet: Sand' ilt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam-D 7 - Hardpan ❑ Adobe ❑ Fill Material _A10-- If yes,type ------------------------------ (Plot ------------------------ -(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 permittecl_if public se s v�able within 200 feet,[ PACKAGE TREATMENT [ ] SEPTIC TANK'X a x 14 ie _ -_________�---- ------------------ Liquid Depth ----- __ F ---- ------------ /15�OC) Capacity _ ype - Materiol_e7eC_6 s7-No. Compartments ------ - ____ . .._:.-.. Distance to nearest: Well _____-�T�� / ___--_____-_Foundation ____.-1®,F______ Prop. Line ___ -- LEACHING LEACHING LINE [ } No. of Lines ________ __ _________ Length of each line.____.__ -------- Total Length _._ --------- � // 'D' Box ----/----- Type Filter Material -_A�-------Depth Filter Material __.______/v a'-' �____-...._- Distance to nearest: Well ----735`x-------- Foundation ___&:?_.5 7------- Property Line __-_� __�...-... SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No j40- Water DWater Table Depth ------------------------------------------------Rock Size _______________________________ Distance to nearest: Well ______________________________________foundation -------------------- Prop. Line -.--___-__-____-..-_-- ; REPAIR/ADDITION(Prev. Sanitation Permit# _____________________________ Date ----------------------------------) I Septic Tank (Specify Requirements) --------------- ------------------------------------------------------------<---------------------------- b ------------- •--•--- t� �.. Z_----- -- � � r--------- Disposal Field (specify Requirements) _______f��_______ .��-__-___-��1�� r �� ---.-------- ---------------- --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------•--------- --------- - ----------------------"- -- ------------------------------------------------------------------------------------------------------------------------ ----------- lDraw 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 By J _ Title x If other than owner) / FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY -----�1_A-. 0--------------------------------------------------------------------------- DATE ------9= BUILDING PERMIT ISSUED ------------•------------- -- ---------DATE ------------------------------- ADDITIONAL ------------------------- -ADDITIONAL COMMENTS ----------- --- ------------------------------------ - -------------------------------------------------------------------- --------------------------- ___ ________________________________ _ ___--------- -------------------------------------- _ ___.___ ___-__________________________________-__ _ --- ------- -- ----- ------ ------ --- - _ - Final Inspection by:_ .j �� Date . - ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M