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FOR OFFICE USE: } APPLICATION FOR SANITATION PERMIT -------------------------------------------------------- Permit No: _.7 _ _._. (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 hereir. described. This application is made in comliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ,�_ ---. ,------ - --- ,/ .Q ------------------ ---------CENSUS TRACT Owner's Name --_/_® ------ -- -- --- --- -- ----- - ----------- . - --- Phone --------------------•--------------- i Address City - --- ------- ---- ---- -- - -- --- Contractor's Name ---- -- - ---- • --------- _ ---- - ----- -e--- ---License # �_y.; _ Phone --------------- installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ---- --- ----------------------------------- Number of living units----------- Number of bedrooms__3_____Garbage Grinder ------------ Lot Size --------------•--- Water Supply: Public System and name ------------------------------------ _________-_____ ----Private [�f Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam:❑ Hardpan ❑ Adobe.E] 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 ifs/, ublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK Y� S. _U ---------� '-----/-�-------`---- Liquid Depth ------ --- ----------- pQ Capacity i- _�_- ?-C-- Type _ 6- ___ Material_'---a— No./Compartments -------------------- 0� Distance to ne rest: Well ------5Q- ` - ---.__--Foundation ----1_o--_--------- Prop. Line -----S______________ �I -- LEACHING LINEj ) No, of Lines ________3------------ Length of each line_______F�-7_____ Total Length __-___Z`� u 4 ` 'D' Box ----/---- Type Filter Material ---iF -IZ-----Depth FilterMaterial ----/1..........___________�Y-V -_ f�Y� Distance to nearest: Well _------S_d----------- Foundation _____-4k--/ ----------- Property Line --- ____..._- V' SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number __ Rock Filled Yes ❑ No i❑ Water Table Depth ------ ------------- --------------------------Rock Size Distance tonearest: Well -----------------------------------------Foundation--- ------------------------------------------ -- 1 Prop. Line ----------------_---- REPAIR/ADDITION ---------------.-_--REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------•-------------_} ..r Septic Tank (Specify Requirements) -------- ----------------------------------------------------------------------- ` Disposal Field (Specify Requirements) ___________________________________ ---------------------------------------------------------------------------------------------------------------------------- ) ------------- 4----------------------------------------------------- - (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, 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 r man's Compensation laws of California." Signed --------- ------------ -- ------- Owner - --------- --- -- By - --------------- ----------- - ------------ Title (If other than owner) `" ---------------- x + FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED - - ----------------------------------------------------- BUILDING PERMIT ISSUED --------------- ----------------- - ----------------------------------------------------------------------DATE ADDITIONAL COMMENTS _ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ---- ti---------------------------------------------------------------------------------- --------- --------------------------------------•- ----------------------------------- -- - - --------- - - - - i Fina Inspection by: ----------------- - ------------------------------------------------ Date -A - ----- ---------------------- '. SAN JOAQUIN LOCAL HEALTH DISTRICT ` E. H. 9 1-'6(3 Rev. 5M