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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT --------------------------------------- - - (Complete in Triplicate) Permit No. Date Issued __ .__-_________________________.__________.________._ This Permit Expires 1 Year From Date Issued r 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION .----------_ ------I-t ~ ----------------------------------CENSUS TRACT ------------ -_. Owner's Name --------------------------- - ---------- -- - -------------------------------------- PhoneQ.2_�_ r1�1. AddressQ six- -por- ------- City ---- -------------- --- -------------- --•- Contractor's Name ----------- - --- -- -------------------------.License #/GZ!L/------- Phone Installation will serve: ResidenceVApartment House'E] Commercial ❑Trailer Court Mote1'E] Other ---------------------------------------•---- 7 Number of living units:-----(---- Number -of,bedrooms --�!<..Garbage Grinder ------------ Lot Size ___f C--_ ----------- Water Supply: Public System and name y ------------------------------_.-.; --_----- ---------•-------•------------------ -----------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E] Hardpan 0 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 s�er is available within 200 feet,) ( i ,D� a PACKAGE TREATMENT SEPTIC 5ize____________�___ ___T__.__f__;___,_ Liquid" bepth ___,��.____.___,:____. � �' uµ . k ,_ r �- Capacity____.__ _ Type _ -- _ _-- -- -- Material_�.afw.t-�*.r�__.: No. Compartments ---------------------- Distance to nearest: Well __:___ _---------------------Foundation"____ __ ____ =_:____ Prop. Line ___ ?�`_____: 1line � Yom.. LEACHING LINE No, of Lines ________________________ Length of each line-_____ .__.___ Total Length _.___ ___________._.__' ' D' box Type Filter Material - --- - -----------Depth Filter Material __=_1 -------------------------------- Distance ------___ _---_--------------Distance to nearest: Well ____, Foundation �____e<_________ ______ Property Line. ------ __._____ ��33 SEEPAGE PIT `f ] Depth ____ � �_____ Diameter. K Number ._____# � Rock Filled Yes ) No'C] Water Table Depth, -_ p.--=---- -------•---- --------Rock Size '1 y ------------------ Distance to nearest: Well _____� _-_ __ ________________Foundation Prop. Line ... 1 � I REPAIR/ADDITION(Prev. Sanitation Permit# __--------_---------------------_____________ Date _________________--___._-__-____) Septic Tank (Specify Requirements) _ ---------------------------- Disposal Field (Specify Requirements) ---�-------—------------------------------------------------ ----L- -----.- -- - -- ------------ -------------- r' ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Dra ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify,,that J1,have prepared this application and that the work will be done in accordance with San Joaquin .Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen County Ordinances, State 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 --------- - - --- ---------- --t--------- ------ Title --------- (If other owner) -FOR DEPARTMENT USE;ONLY 5 APPLICATION ACCEPTED BY .- DATE /------------------ BUILDING ---- 7BUILDING PERMIT ISSUEDy DATE r ADDITIONAL COMMENTS _/(-a -"`¢ C fad } , /d _-------- . ---------------------------------- --- ----- �- / -------- �!tg-t� - ------- ------------------- ---------------------- - � 7`"a- --r '__ -V Final Inspection b - � / _ P Y �-�� ---------------------------------- ------------------ --------------- * a �`7'r JOAQUIN LOCAL HEALTH DISTRICT iE. H. 9 1 68 Rev. 5M 'i -,,SAN '! F