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FOR OFFICE USE: APPLICATION FOR .SANITATION PERMIT --------- - -----`---- ------- rte/ IR (Complete in Triplicate) Permit No. --------------------- ---------------=-------------------- ---------------------------------- '" This Permit Expires 1 Year From Date Issued Date Issued C)2-S CW*6 r-492— Application"is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described..This applicatiori,is made,in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO 7 c`_ �t"�Z,4�----"� ----dUc - ---CENSUS TRACT -------------------------- Owner's Name --- - ------ ------I-----------4<--- - �--,- - -------------------- - - ---•--- --•- -------- ----------------- Phone ------ ----------------------------- AddressO _.�_----,----------------------------------------------- City J"� e- a-' --------------------------- ------------------- Contractor's Name ____ - Ql-- - ------.License #� ..- Phone . Installation will serve: Residence ❑,Apartment Ho a f❑ Commercial ❑Trailer Court i❑ J I Motel ❑Other Number of living units------------- Number of bedrooms --------- Grinder _._______._ Lot Size --------------------_-----------____________ Water Supply: Public System and name ---------------------- `------------------------ ----------------------------------'----------------------------Private C Character of soil to a depth of 3 feet: Sand'❑ __Silt❑ �< Clay'.E] Peat ❑ Sandy Loam fff'�' Clay Loam 'D 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 permitted-if public sewer is available within 200 feet,] PACKAGE TREATMENT f ] SEPTIC TANK-f ] Size-�--------------------------------------------- Liquid Depth -------------------------- 4, + Capacity +� -- -- - .Type --------- --------- Material---------------------- No. Compartments 4 Distance to nearest: Well __________"—-------------________Foundation ---------------------- Prop. Line _________:_-________ LEACHING LINE [ ] No. of Lines ---------------- ------- Length of each Eine-f-------------------------- Total Length --------------------_-••__-- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------__.--.-----__----------------------- l Distance to nearest: Well ------------------------ Foundation ------------------ ----- Property Line ---------------------- SEEPAGE PIT Depth ------------- Diameter _______________ Number-------------___.____. ------ Rock Filled Yes ❑ No 0 Water Tablet Depth ------------------------------------------------Rock Size -------------------------------- R 14 Distance to nearest: Well --------------------------------------=Foundation __------------------ Prop. Line ------------------__-- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------- ---------------------•Date -------------------------------- r� F Septic Tank S ecif Re uirements s - Disposal Feld (Specify Requirements] p 3 ------- --------------------- �----------------------------- ------- ------------------ ----------------- ----------------------------- -- ---------------------- ------------ --------------- -------- - - ---------------------------------------_ -------------------------------------------- ------------ --------------------------------- (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 "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.." I s r Signed ----- ------ ``------------------------------- - # ------. a Owner _ BY ----------- ----------- ------- ----------- -- - Title:_ > -------------------------- (!f'other than owner) -�'-- FOR DEPARTMENT USE ONLY APPLICATION BY . � DDATEATE -07� BUILDING IT ISSUED ------------------------------------- ------------------ -- ------------------ ---- ------------------ ADDITIONAL COMMENTS ----------- - --------- ------ -------------------------- --- ---------- -------------------------------------------------------------- -------------------------------------------------------------- 1! Final Inspection by: s-P�e.__- _ Date _________________ _ ----- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'h8 Rev. 5M.