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` FOR OFFICE USEiN s APPLICATION FOR SANITATION PERMIT , 6 Permit No,. -------- ---- - -.... (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 an install` the wor 'herein described. This application is made in complian :.vwi#h Co my rdinance ;Na.C,,��d xist'ra.ges' ngulations: V 1 U-{JCCvic.rp - ------------------ CENSUS TRACT ; ON ------- Own er'Ds Name LOC ----- ---------------------------------------Phone ------------------------------------ Address ------- City --------------------------------- .. r nS - License # - Y�,a�-------- Phone ------------ Contractor's Name CQ�Si�.�C/t4. -5.�.... = /j Installation will serve: Resident partment House Commercialrailer Court 11 M el ❑ Other - ------------- �, _ Number of living units:---- ------ Number of bedrooms --r.___-_..Garder hta]-_ Lot Size t-- ---------------- M -Private Water Supply: Public System and name ------------------------------------ --------------------------------------------------------------------- EF—� II Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •0 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,) Q PACKAGE TREATMENT [ ] SEPTIC TANK'[ l Size------------------------------------------------ Liquid Depth --------------------------- Capacity -- --- 1 Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --- •----------:---- Distance to nearest: Well --------_---.-- p �i ---------------- ---Foundafiion ---- -----------.- Pro Line ----------••---:----•- LEACHING LINE [',] No. of Lines ------------------------ Length of each line--------------------------. Total Length ----------- _-------------- II 'D' Box ------------ Type Filter Material ....................Depth Filter Material Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line_ -----.__--...._._._-.--- SEI_PAGE PIT [ ] Depth - Diameter ---------------- Number ---.------------------------ Rock Filled Yes ] No WaterTable Depth ------------------------------------------------Rock Size -------------------------------- j. ------------------------------- , Distance to nearest: Well --------- ---------------------------------------Foundatio �"'�"---�Prop. Line -------_------------ ------ Date ---- �eT -6 Sanitation Permit�k -------- ------------------- � �• REPAIR/ADDITION A aDk{OP(Prev.'ify Requirements) ------------------------------------------------------------ /---------- ------- ------- ------------------ - ---------------- --------- ---- Disposal Field (Specify Requirements) ........ ---- vhf -------------------------------=`--------------- ------------------------------------------------------------------------------------------------------------------ ----s------------------------ i p (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,I 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 - ------ ---I�---------"- -- ------------------------------------------------ Owner it ""'"'.• By ----- --------------------------------- Title -------------------- ----------------------- -- ------------------------ (l other than owner) j FOR DEPARTMENT USE ONLY APPLICATIL DING ON ACCEPTED BY ------ ------------------------------ ----------------------------------- DATE ... BU ,ISSUED --------- ---- ------------------------------------------------------- --------------DATE ..-- -------•----------------------------- ADDITIONAL CO MEN75 - -------------------- - ------------- - - - ---- -- ---- -----Z ------- � � --- --- _ ! ------ ------------------------ --- r ------ ------ 1) -------------- Final I spection by:�------ -"- -- -------- ----------------- SAN ---------------- Date - � li SANJOAQUIN7�}LOCAL /HEALTH DISTRICTV;2 ell E. H. 9 1[68 Rev. 5M�A I i-10 cI•W.� in�\_o 40_-_ -- A 0�•-�-� � .