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�i �o OFFICE ��: = APPLICATION FOR SANITATION PERMIT - -------------" ------------------------------------ .- Permit No � ,. 3S (Complete in Triplicate) ____ -- ----------------------------- 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 ADDRESS/LOCATION ----'---'- _----- ��-G'�,�Q--------------------- CENSUS TRACT --------------............ Owner's Name �!?�� t -- ---------Phone --------------------------------•--- Address r'�`1' a/ City - Contractor's Name --- --_---- ---- -------.License Phone ............ Installation will serve: Residence artment House-[] Commercial❑Trailer Court ;❑ Motel ❑ Other '------------------------------------------ Number of living units:.__. ___.__ Number of bedroom ._.Garbage Grinder/___ Lot Size ___ - ` -- �------------------------- r ` Water Supply: Public System and name --- a11_ .----CCs--------- ------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'[-] Silt❑ Clay ❑ Peat❑ Sandy Loam ,F] 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'[ ] Size------------------------------------------------ Liquid Depth ___________-___-________- \ Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ --------- -- Distance to nearest: Well ------------------------------------Foundation -------------------- Prop. Line----------------------- A LEACHING LINE [ j No. of Lines:`_________ ______________ Length of each line---------------------------- Total Length ___________-._____________-- 'D' Box ------------ Type Filter Material --------------------Depth Filter .Material ----_--------------------------------------- Distance to nearest: Weil ________________________ Foundation __--_________ ------------ Property Line ___________-..__..---_ . SEEPAGE PIT [ ] Depth ____________________ Diameter ----- ---------- Number _._____________._._____._'. Rock Filled Yes [] No 0 -Depth Table Depth ------ ----------------------------------Rock Size ---------------- ------- k Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------.-.-_.-- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________.__________________-______) Septic Tank (Specify Requirements) -------- ----- ------- -------_------- ---..._.----------- Disposal Field (Specify Requirements) _I_Z __. ----_ ------------------------ 1 ________________________ ��/ ----------- ------------------------ 01 y -------- ---------------------------- -------------------------------- ------------------------------------------------------------ / (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in l 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 -----/ __1� ��P- -..--------- her than owner) GG� � ---'----"-------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- _______ ______ -- --- -------------------- ----------------- . DATE " ---------- ----76..-'--- BUILDING PERMIT ISSUED --------------------------------------- ----------- -------------------------------------------DATE ADDITIONALCOMMENTS - -------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------------------- --------------------------------------------------- ---------------------------------------------------------- --------------------------------------------------------------------- --------- ----------- --- ---------------------' -' -- ----------- --------- -- -- -- ---------------------- --------- - - - - - -- --------- --- ---------- -- - -- -- ------------ ---- ---------- - -- - --- Final Inspection b ___Date - `--- - -- -- " SAN JO QUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M