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►` FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . ca Permit No. ------------- --------- -------------- ----------- (Complete in Triplicate) --------------------- -------------- V;5L -- -- 7/ -------- ----- - Date Issued -�-=-----•-------• This Permit Expires 1 Year From Date Issued # -------------------------- - - ---- - - %z 11 Application is hereby made to the San Joaquin Local Health District for a permit tb construct and install the work herein PP described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: - ' ------CENSUS TRACT ---------------------- ---- JOB ADDRESS/LOCATIO}N ___X- - Owner's Name _____J___ _ ______________________________ __ ------ - --- -'--C--=---.P one y--� -------- ----� --•--- -----•---------- ------ --- -- Address _- Cit r Contractors Name --- /Ap----------------------------------------License 1 Phone Installation will serve. Residence E]Apartment House❑ Commercial Trailer Court ;F1 Motel ❑Other --- ge Grinder -- -------._ Lot Size _d _rpt=', J � ---------- - Number of living units:. -_� Number of bedrooms __�--_Garbo __ private`�' Water Supply: Public System and name --------------------------------------------- ------------------------------------------- Character of soil to a depth of 3 feet: Sand% Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe M 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,) �1 I PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size... ~A--- 'f Liquid Depth _ ----•- "No. Com artments --- s _-�`lVlaterial__C - P �� Capacityf-x_"O��------- Type Distance to nearest: Well ____--_--_C9� --------------Foundation --------- Prop. Line t ------------ f i '�Q° Total Length ..'� LEACHING LINE [ ] No, of Lines _____ ___---_ " -------- Length of each line----- --------- 5 -- - 'D' Box ------------ Type Filter Maters �-- Depth Filter Material ---- ----•----------f ------------ 0 � Distance to nearest: Well ____ - -- ------- Foundation ------- --------------+Property Line --- - ------------------ SEEPAGE ------- --------SEEPAGE PIT Depth -------------------- Diameter ---------------- Number -------------------- ------- Rock Filled Yes ❑ No i❑ Water Table Depth Rock Size -----------------------I-------- Distance to nearest: Well ----------------------------------------Foundation -------------------. Prop. Line --..---------_------ REPAIR/ADDITION(Prev. Sanitation Permit�# -------- ------------- --------------------- Date -------------------- ) F Septic Tank (Specify Requirements) ----------------- -------------------------------------- ------ Disposal Field (Specify Requirements) ----------- - --------------------------- -------------------------------------------------------- - --------- ---- ----------- ----------- ----------------------------------------------- - ------------------------------------------------------------------------ -- - - - - - [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 Workman's Compensation laws of California." Signed ---- a-- - ---------------- Own _ er ----------- Sitle --------- ------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- .- - ------------------------------------- ------------------ DATE _ " l:1 Z' -- - ----- BUILDING PERMIT ISSUED ---"---------- ---------------- ---------------------------- ------------------------------DATE ADDITIONAL COMMENTS ------------------------- -- ----------------------------- ---------------------------------------=--------------------------- ----------------------------------------------- -------------------------------------------------------------------------------------------------- _ _ __ -------------------------------------------------- Final Ins ection b Date SAN JOAQUIN LOCAL HEALTH DISTRICT C u a 1_'AA Rav 5AA