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f FOR OFFICE USE: 1 APPLICATION FOR SANITATION PERMIT a = `� r' Permit No: 0 f- Y (Complete in Triplicate) --------------------------- This Permit Expires 1 Year From Date Issued Date issued a Application is�4iereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thi application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .---� ------ ----- �"� :�lr0_-, CENSUS TRACT --3i -- - --- ------Phone - - -L." •- Owner's Name --------Ft" e� Address ----P-'-� 'J1 r l t----- ---------- ---------------------------------- - City -S/ Ik --s ------------------------------- Contractor's Name ----------- ----------------------------------License # ---------.-------------- Phone ---------------------•-- �tResid nc ❑ ❑ e1•Court ',❑ Installation will serve: Residence artment House Commercial : Trail Motel ❑Other -------------------------------------------- N ------------------------------------------- Number of living units:-----_1__._ Number of bedrooms --. ------Garbage Grinder --- -`---- Lot Size --�G_�'�?�__1._..... Water Supply: Public System and name -------------------------------------------;----------------------------------------------- -------------------Private ❑ Character of soil to a depth of 3 feet: Sand.E] Silt❑ Clay.❑ Peat.❑ Sandy Loam -❑ Clay Loam Hardpan E:] Adobe ❑ Fill Material ------------ If yes, type -- rte,, (Plot plan, showing size of lot, location of system in relatioh to wells, buildings, etc. must be placed on reverse side.] W 3� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:( ] Size--------------------------------------------- --�j+quid Depth -------------------------- V Capacity -------------- Type -------------------- Material---- ------------r ;.No. Compartments -----------------:.... Distance. to nearest: Well ------------------------------------Foundation, +--r"-------- --.Prop. Line ----._.-------------- - i � , LEACHING LINE [ J No. of Lines ------------------------ Length of each line------------------ .J__--Total; Length ----------- --------------- 'D' Box------------- Type Filter Material --------------------Depth Filter Material 1-----------------------------------=........ Distance to nearest: Well ------------------------ Foundation .---------------------- -Property Line. --------------- --------- SEEPAGE PIT [ ] Depth ------------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No.,O Water Table `Depth`----------------------------==- Rock"Size------ Distance to nearest: Well -----------------------I-----------------Foundation -------------------- Prop. Line --------..------.--_-- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------=� Septic Tank (Specify Requirements) ------------- -------------------------------------------------------------- ----------------- --- ------------------------- -------- Disposal Field (Specif Requirements) j --------- $ry of~ ------ = `A ` ---------------------------------- -------------------------------------------------------------------------------------- ------------------- ----------------------------------------------- (Draw existing and required addition on reverse side) ' d 1 hereby certify that I have-prepared this application and that the work will be done in accordance with`San�Joaquin County Ordinances, State Laws, and Rules and Regulations of the.San Joaquin Local Health District"Home owner or-licen- sed agents signature certifies the 1`6116wing: E "I certify that in the performance'of the work for which this permit is issued, I shalt not employ any person in such manner as to becomeesc t to rkm .* ,Co ion law of California." Signed --- -------------------- Owner } By ----- ------------- -------------------------------------------- _ ----- ------- (if - w- _ ______ Title'` �` -- - ------------- ------- (if other than owner) R ARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ---- ------------------------------------------------------- DATE �f ✓- �--------------- BUILDING PERMIT ISSUED;.-------- DATE ADDIT AL COMMENTS ___--- _------- - ------ ---- -- ------ - / �- - s-' QY-�-- ------- --- ---------------- --- - ------ ------------------------------------------------------------ --------------- W - --- - .... -._ --,�---_ ------ Date Final Inspection ---•------------ - --------------------- ------------------------------------- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M ; ;•. a *�