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FOR OFFICE USE: ^� 17 0-6 APPLICATION FOR SANITATION PERMIT 3 i3 3 (Complete in Triplicate) Permit No: --------..I-------- -------------- ------ --------------- t ________________ Date Issued _3-__r�_73 ______________________________ This Permit Expires 1 Year From Date Issued i s 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 ith Count Ordinance No. 549 and existing Rules and Regulations: f .. JOB ADDRESS/LOCATION .___- --- ---� -----_--__-- --.__s---- --- S TRACT ----------------_-----__ Owner's Name --------- - f-------- - ---- --- --- --------------------------------- Phone Address ------ --------- - . Cityf - ----------------------------------------------------------- Contractor's Name _,dE' s<.License --- Phone 3— --- Installation will serve: Residence*Apartment House❑ Commercial :❑Trailer Court Motel ❑Other -------------------------------------------- *-Po' �e Number ---------------------------- ------------ Number of living units:_.-./ Number of bedrooms __Z___Garbage Grinder _` ". Lot Size _ � '----�'___. Water Supply. Public System and name ------ ----- -------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ 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.) t NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK:[ lel-Vt S l'' R ----------------------------------------------- Liquid Depth -----_---------------.----- i Capacity -------------------- Type -------------------- Material------------------ --- No. Compartments ................. Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line -------------------- LEACHING LINE . No. of Lines __._. . Length of each line.___._�r_��__i___..____ Total Length ,____� _r____________ I 'D' Box __/ __-_ Type Filter Material _ ____Depth Filter Materialr....................... I 01 Distance to nearest: Well A41__41:��Foundation ___164______________ Property Line -_A..........I...... � SEEPAGE PIT Depth Diameter Number ------ol-e----------------- Rock Filled Yes;[ ' No 0 I Water Table Depth ------ --p__:_____.________________Rock Size ---_- , E ------------------ >,&- r � r Distance to nearest: Well ._ __-�� _' �=________Foundation ---- Prop. Line ___---__--_______ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------------------------------------------ Disposal Field (Specify Requirements) - r (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 worts 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 ------ --------------------------- ------------ ------ ---- -- -- -- - (If other- an owned FOR DEPARTMENT USE ONLY If ACCEPTED BY ------ - - = - - - ---------------- DATE ------ /-1 - ------------------ APPLICATION + BUILDING PERMIT ISSUED -- ------- -------- ----------------------- ------------------ --------------DATE ------------------------ -- ADDITIONAL COMMENTS = t1�� ) -� ----------------------------------------------------------=--------------------------- - -------------------------------------------- --------------—----------------- J --------------------------------------------------------------------------------------------------- Final Inspection --------------------------------------------------------------------------------------- ------------- --- ---------- --------------------------- ------------ I ---- --------------------- ----------------------------------------------------------------------- P Y ---------- - ------------------------ Date -------- .- 7-1. SAN JOAQUIN LOCAL HEALTH DISTRICT 1 I E. H. 9 1-'68 Rev. 5M