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FOR OFFICE USE: ` APPLICATION FOR SANITATION PERMIT Pe9 ----------- --------------------- --- rmit No. .7-l-- 1 • (Complete in Triplicate) --------- --------- ------------------------------------ 't -----------------------------------------_--------------_ This Permit Expires i Year From Date Issued bate Issued -.9 '.ZV-7 J Application is hereby made to thel Son 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: i r i JOB ADDRESS/LOCATION ________ wr ------------------------CENSUS TRACT -------------------------- ._ '__` _3 , Owner's Name n _________________ _ - Phone "- _ Address --- ---------------- 1p ----------- -------- //{ - 1` GtY -------------------•-------- Contractor's Name ___ - r __.License. # L 3 _Y phone ______________________________ _______ ---L ��--- �________________ _ Installation will serve: Residence []Apartment House'❑ Commercial:❑Trailer Court i❑ Motel ❑ Other'.'_ ____ Number of living units:------- ___ N�tuber of bedrooms -------------Garba_ge Grinder ------------ Lot Size _____________ ________._-_.----.________ Water Supply: Public System and name --------------------�---------------------- ------.----------------- ----------------------------- ------Private E Charactet of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ] Hardpan l] 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.) ap NEW INSTALLATION: (No septic tank or seep �� '- ge pit permitted if public sewer is av -lable within 200 feet,) PACKAGE TREATMENT SEPTIC TANK 7 SizeX_��_ S_�__.__________ Liquid Depth __ r s" Capacity �C�_` - Type _________�__ �____ Material_ -Q—----- No. Compartments __c��............. v -tel Distance to nearest: Well _----.----_-9d ___Foundation ______ prop. Line ____S__-- I'E LEACHING LINE [ No. of Lines ---------4----------- Length of each line----.___-r _�--------- Total Length ___/_G D' Box -_ ___.___ Type Filter Material __rSJZ__-----Depth Filter Material ----�1Q_____-___________________________ Distance to nearest: Well ____-S 0 r________ Foundation __.__..�_f?__-________ Property Line __- ........:.... € ;-SEEPAGE PIT [ ] Depth ____ ___._ ❑ ❑ _________ Diameter ________________ Number-________�_______-- `_______: Rock Filled Yes No d i i f_. Water Table Depth --------------------------------------- --------Rock Size ----------------- -----: Distance to nearest: Well _____________________________ "_Foundation '_________,________ Prop. Line ._ -__..._...: r REPAIR%ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) `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. Hoare owner or licen- sed agents signature certifies the following: _ l ! "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." r f Signed -- ------------ Owner ------- -=-- BY ----------------------------------------- --------- --------- - Title (If other than owner)' ' FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .` -- ----=---- -=---------------i------------------------------------------------------- ------ DATE --- --------------- BUILDING PERMIT ISSUED ----------- ` ---------------------------------------------------------=--------------DATE _.._--------------------------------------- ADDITIONAL COMMENTS ----------- J---------------------------------------------------------- ------------------------------------------------------------------------ - - I - - --- ---------------- � --- ------ � --- -------------------------------------------------- ------Final Inspection by: /----- ---------------- -- ------ --------------- --ate I SAN JOAQUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'b8 Rev. 5M.