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FOR OFFICE USE: APPLICAT18WFOR SANITATION PERMIT----------------- ---- Permit No. q(Complete in Triplicate) ---------- ----------------------------------------- -------------------------------------------------------- This Permit Expire's 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health+'District for a per to construct and instpll the work herein described. This application is made in compliance with CoA ty Ordinance No. 549 and existing Rules and Regulations: I � x , ,ryM.---.-v- -------•-�-----'- -----------CENSUS TRACT - ------------- -•-.-JOB ADDRESS/LOCAT ] i - _ ___ - ------Owners Name Address ! =,. : - - City i ]> _ _ -• s --------- - Contractor's Name . _ -'- -----------------.Lic6tas� # ,l �c� Phone ,r- Installation will serve: Residence artment House` Commercial [ ]Trailer Court ;F p ❑ Mote! ❑ Other `" --------------------- t�} Number of 1-iving units:.-----l--- Number of b omsT,_. G rb`farge G finder -_ _ _- Lot Size -__ - _ _L!_ __ --------- Water Supply: Public _ic System and name ______ _____ _____;__._C1' _"`�"�"`___ -___ _ _ ________________Private E]Character of soil to a depth of 3 feet: Sand'❑ Silt El Clay ; L at andly L ❑ Cl ay Loam ❑ Hardpan E] f Adobe ill Materia) -- If yes,type ----------1---------------- s [Plot plan, showing}� size of lot, location of syst6m in' relation;to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepgte.pit-permitted if �ublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] ,. Size" ---------------------------------- Liquid Depth ---- ---------------------- A,. Capacity -------------------- 7-Ype -------------------- Material--------- ------------ No. Compartments --------------_--•-- Distance to nearest: Weld=------------------------------------Foundation ---------------------- Prop. Line ---------------------- i LEACHING LINE [ ] No. of Lines __.____________ --------------Length of each line__-_-___=__-__-_------____ Total Length 'D' Box ------------ Type Filter Material ___________________Depthb Filter Material ------_.-------------------------- _----- 1Di-stance-to nearest: Well--w---- --------------- Foundation------------------------- Property Line_ -------------------- SEEPAGE PIT ['] Depth -------------------- Diameter -------- Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ---------------------------i---------------_-_Rock Size -------------------------------- Distance ------------------------------ Distance to nearest: Well --_--_---_---_--!_--------------------Foundation ---------- --------- Prop, Line _----_________-____-__ i t _ . -__ -, � , REPAIR/ADDITION(PreOSanitation Permit# -------------------------------------------- Date -----------------------------------1 Septic Tank (Specify Requirements) -----__--__________ - / t r� ----- --- --- - isposal Field (SpecifyrRe uirements) ____________ _ ---------- -- -;------ ------------ -------------- -- - ---- ---- - - --------- -- . --- ------'��---------------------------------------------------- -------------------- -- ----------------- -----=------------------------ i 1 ----------------------------- l (Draw existing and required addition on reverse side) 4 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws bf California." Signed I Owne0)xi By ----------- -------- ---------- --- ------------------ ----------------- -- - �� - -- - =---- ------------ Title -- -`----- o her than owner] I/ t FOR DEPARTMENT USE ONLY R APPLICATION ACCEPTED BY e -----N-6- y( a- Y --------------------------------------------------- DATE 6------- BUILDING PERMIT ISSUED --------------------------------------------A----'------------- ----------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ---------------------------------------------- --------------------- -------------------- --------------------------------- - - 4 --- -------- - - ---- - -- - -- - -- - - - - - - - -- -- - r ---- - ;- �� . . -3A- ---- ---- ,- Final Inspection by: _'.-------- J��_________U__t*�_-__ _ Date -— ------- -'-----------,--{��{�- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M