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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- Permit No., __1 (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 herein described. This application is made in compliance with County Ordinance-No. 549 and existing Rules and Regulations: 11 � 4_3 W11x)qvT'>WJOB ADDRESS/LOCATION ./ '' ''__+ NS6S TRACT - 5- -� v Owner's Name ------ ----------------------- - -----.Phone ---------------------------- Address ¢ -�'`' i�---------. City - ' ---------- - Contractor's Name r!^^^xr .. �a `�, ------.License # / /'- - Y .- Phone Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ?❑ Motel ❑Other - -d-aY - Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size -.-------_.____------------.---_-------.. r Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat [lr Sandy Loam ❑ Clay Loom '[:] 4 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.) NEW INSTALLATION: (No septic tank or seepage pit permittedLfpublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [t'j SizeSE --x l&--OF X r`a Liquid Depth ----- ------------.--- A_C e -: ,- Material--�-.----------- No. Compartments -�-- ---- ------ Capacity _ _ Type - ^� Distance to nearest: Well -- -------100-----------------Foundation . LIP----------- Prop. Line -----11 ----f----------- g� 4 [ l No. of Lines --------3------------ •.Length of each line---------1-a-�---.------ Total Length ,--- - --------------- t /0 'D' Box .--- Type Filter Material ----.S--I9-------Depth Filter Material ----------f ----•------------------ -•- � - Distance to nearest: Well --------1--OC?------- Foundation ---- --------------- Property Line __75-•----... 3 SEEPAGE PIT e[ ] Depth -------------------- Diameter ------------ --- Number -------------------- ------ Rock Filled Yes '[] No C] Water Table Depth ------------------=------------- ---------------Rock Size ----------------- -•---- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. -Line --------------....... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} , Septic Tank {Specify Requirements) ... w -y ... .------------------------------------------------Disposal Field (Specify- Requirements).---`-- -=--=--=--------- ...------------=='-------------------------------------------- --------- ----- -- ---------- -------------------------------------- -------------_I-----,-.--,.------------------------- ------- ------------------- -------------- I -1-------- - -- s- F ----------------------------------------------- {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 ------------------ -- ------- --- Owner ------- --- -- . Title Q r__s R-------- --------- -------------------- (If other than owner) - - - FOR`DEPARTMENT' USE ONLY-- APPLICATION ACCEPTED BY -h ---------------- -a-le-C ------------------ -- ------. DATE _ r----. -- ------- BUILDING PERMIT ISSUED -- ------------------------ ---------- ------------ ---- --DATE -------------------------- ----------- -- ADDITIONALCOMMENTS ---------------------------------------- --------------------------------- -------------------------------------=--------------------------- ------------------r� , --------- ------------- ----------------- ------- - w ------ ---------------------------------------------------------------------------- --------------------------- --- ----- - _ Date �. , .- ------ -- - ---- Final Inspection by, ---- �:�c.2�-- SAN JOAQUIN LOCAL HEALTH DISTRICT (; E. H. 9 1-'6S Rev. 5M