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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. - ------------------------------------------------------ (Complete in Triplicate) -- --------------------------- - ----=-- ---------- Date issued ------�-�--7 v This Permit Expires 1 Year From Date Issued Application hereby t s the icomplianceJoaquin Local District ominstall the rein described. Thisapplication applaonimaden wih County Ordinance N549 and existing Rules and Regulations: - CENSUS TRACT JOB ADDRESS/LOCATION ^7 -------------- Owner's Name _41f ------------------Phone ---------------------------- ------- Address f - - ------�- &--- -------------- City ---- '�'"-- ,,� - ----- ---------License #1�p3��------ Phone -__ ----------------•-----•--- Contractor's Name .------- �t�- -a= `�' -'�"`�`'` Installation will serve: Residence p 'A-partment House❑ Commercial :OTrailer Court Motel ❑ Other -------------------------------------------- Number of living units;-----1------ Number of bedrooms Z------Garbage Grinder ------------ Lot Size ----------- ------- Water ------------------- Water Supply: Public System and name --------- - --- -- ---- - ----- -- ----- -----------------------------------------------------Private F< Character of soil to a depth of 3 feet: Sand'❑ TSilt El Clay ❑ Peat❑ _Sandy Loam ❑ Clay Loam l_� 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,) w SEPTIC TANK' Size__Mp--_fiY__q_�X---�'--f--------- Liquid Depth ---y-------------- PACKAGE TREATMENT [ ] C� � o O tit-, � Material_ ' �'------- No. Compartments ---______............. � Capacity ---�--ra----------- Type 1 Distance to nearest: Well -- ` ""�`tea'`-..-------Foundation ----1_V----------- Prop. Line _.. � No. of Lines g a --------- LEACHING _____ LEACHING LINE �� --------�- -�- Len th of each line. gip________________ Total Length ---___ ----..----- - 'D' Box ----------- Type Filter Material ---_ 13--------- Filter Material -"------ ----------.............. Distance to nearest: Well .... -{Foundation ---___.-"_ Property Line ------__________ .... SEEPAGE PIT [ ) Depth - ------------------ Diameter ! = Number -_- Rock Filled Yes ❑ No Water Table Depth -"-_- _----Rock Size ----------------------------- - - A ` --Foundation ------------------ Prop. Line -------_----------- Distance to nearest: Well ----_-------- 6 Date.---'------------- 1 REPAIR/ADDITION(Prev. Sanitation Permit T# ------------------ g Septic Tank (Specify Requirements) -------------------------------------------- ---------- --------"--- - ----------------------------------- Disposal Field (Specify Requirements} _--_-- ---------------------- ---------------------------------------- ---------------- -- _ , _ -_ _ A_�- _ w _ � - ----------------------------------- (Draw existing and required addition on reverse si e I hereby certify that 1 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: "1 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." r Signed -------------------------------- --------- - __ Owner j� Title --- -- ----------------------- ------------------------ (If other than owner) DEPARTMENT USE ONLY DATE _-. -: =7 ------------------- APPLICATION ACCEPTED BY ------------------------------------------------------ �""� DATE -:--- ------------------------------------- BUILDING-PERMIT ISSUED -- ----------------------------------------- ------- ADDITIONAL COMMENTS ------- --- -- I -=-------------------------- ----------------------------------------------------------------------------- ------------------------------------------ ------------- ----- -- ---------------------------------- - - -- ------- r -- Final Inspection b -----------------Date ---- �- --- - - --- SAN JOA !N LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M