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FOR OFFICE USE: .....................................I........... APPLICATION FOR SANITATION PERMIT ........... Permit No. -................... memplete In Triplicate) P .............. ....................w-...... This Permit Expires I Year From Dotip issued Date Issued ....... Application is hereby made to the San Joaquin Local Health District for a permit to const described. This application is made in compliance with County Ordinance construct and install the work heroin No. JOB ADDRESS/LOCAT 9N 549 and existing Rules and Regulations: , .......W .. ...... ...... .CENSUS TRACT ....................... Owner's Name ... ne ......Pho Address ............ ....... Ch tyl` -sic --- -- - - - Contractor's Name ... ...............License*Q. 47 _ Phone . ..---••---..._-__--- - - ----- Installation will serve: Residence JA Apartment Housefl Commercial oTraller Court Motel El Other.......-•------•-•................ ........... Number of living units------ Number of bedrooms ,3__-.--Garbage Grinder ............ Lot Size . ........... Water Supply: Public System and name .................................... Character of soil to a depth of 3 feet: Sand t] Silt Loom Clay 0 Peat 0 Sandy--------*.........................Private 0 Hardpan 0 -Adobe o FilIM6terial ............ if 0 Clay Loam 0 yes,type................ ............ (Plot plan, sho wing size of lot, location of system in relation. to wells, buildings, etc. must be placed on reverse sideA. NEW INSTALLATION: . (No septic tank or seepage pit permitted If public sewer Is available within 200 feet) PACKAGE TREATMENT SEPTIC TAMC ........... ....... ...... ...... ...... Liquid Depth .......................... . Capacity ------------_-- Type ...... Material...................... No. Compartments ..................... Distance to nearest: Well ....................................Foundation ...................... Prop. Line ..........*............ LEACHING LINE, No. of.Lines ------------------------ Length of each line............__.............. Total Length _......._-_- D' Box —,........ Type Filter Material ....................Depth Filter Material ............................................. Distance to nearest. Well ........................ Foundation ......... ....... ...... Property Line .................. SEEPAGE PIT ODepth ---------- ......... Diameter ................ Number ........-......-...----•--.. Rock Filled Yes [I No 0 Water Table Depth ................................................Rock Size ................ ............... Distance to nearest: Well ....................................... Foundation .........I.......... Prop. line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ................... ........................ Date ................................. Septic Tank (Specify Requirements) ...................... . -- --------*........... -------------------------- ....._-.------• .....---------- Disposal Field IS pecify Requirements) .... ........ --------------------------- ---- ----------------------------------•••-••./---:77�_...J4�vl ............... ................ --------------------------- -------------I--------------- ----------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and than the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,District. Home owner or licew sod agents signature certifies the following: "I certify that In the performance of the work for which this permit Is Issued, I shelf not employ any person in such manner - as to become subject to Workman's Compensation laws of California." Signed - ---- --- ---- -------------------------------- ---- Owner B ------- By -- -- ------------ Title (if other than ned --------------------------------------------- ==.�FOR�DJEEOPA�RTMET USEqNLY APPLICATION ACCEPTED BY ............................ ...... ------I- --------- -- ---- ---- - ------ DATE -------------•---= BUILDING PERMIT ISSUED -------------- --------------- ��_ r_o------ ----DATE - --------------------- --------------- ---- ------------- ---------- -----------**-------- --- ADDITIONAL COMMENTS ---- --- ------------------ -- - --------------------------- ------- ------- ----------- ----------------------w........ -------------------------------------------_--------- -------------- ............. ....... ---- ------ .. .....I...... -------------- .1-1--------------------------..................................... ---------------------- --------- ------- -- --- ---- - - -- -------- -- -----I............. ........... .. y. ---- - -- ----- Final Inspection.by- -•-----••- _ ---- ------- - --- - ........... - ----- -------------------------Date .... EH 13 211 1-68 Rev. 5N SAN JO "OUIN LOCAL HEALTH DISTRICT - 8/74 3M • 0