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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT € --------- ---------------------------- ' (Complete in Triplicate) Permit No. ----------------------------------------- -------"---- Date Issued --- -----This Permit Expires 1 Year From bate 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: X07 / /&M/45 � r JOB ADDRESS/LOCATI ---�{------------------------------------- ----- -- ---- --- J + Us TRACT ____=- _-- _ _ Owner's Name � -��`,-r�-�-------� - --'------- �'--a--n--- -------------------------} ----------------Phone _----- - --- - - Address -------------------�1Z •---------_--------------•--------•------------------------- City -=--------------------------•----------------------------------------------- - � i Contractor's Name -------41- i`' 5.1---------------------------------------------------License # ------------------------ Phone ----------------------•-_-_ t Installation will serve: Residence KApartment House❑ Commercial :❑Trailer Court 0 Motel ❑Other --------------------------- ----------- Number of living units:_________ Number of bedrooms _______Garbage Grinder ____________ Lot Size --- ....... Water Supply: Public System and name - l 4..Private. Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam;❑ 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 [ SEPTIC TANK Size--- vr'X-- ------------------------ Liquid Depth ___7=_/ ______,____ `V` __ Capacity _l-o ---,-- Type Ab Materiufi_---------------------- No. Compartments __- -------- W Distance to nearest: Well ------s-&_ -------------------Foundation -----/0 Prop. Line --- ---------------- LEACHING ------------- � ! LEACHING LINE [ No. of Lines _______________ Length ofeach line____---_-f0l.-".------- Total Length f--�#b__.___________ Y 'D' Box } ___. Type Filter Material 2tC-1C.__Depth Filter Material ------19 ________----------------------- Distance ______`--__-__- -___ Distance to nearest: Well --` _-_. ______ Foundation __I ______________ Property Line SEEPAGE PIT [ ] Depth ____ ______________ Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No I❑ Water Table Depth -------------------------------____......Rock Size -------------------------•----- Distance to nearest: Well ________________________________________Foundation _________________ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) ' r SepticTank (Specify Requirements) ----------------------------------------------------------------------------•--- ------------:------------------------------------------•-•- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------•-------------------------------- --------------- J —------------------------------------------------------------------------------------------------------------------------------------------------------------ � -----------------------------------------------)------------------------------- ----------------------------------------------------------- I @ (Draw existing and required addition on reverse side) 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: ' "I certif hat in rhe erfo ce of the work or which this permit is issued I shall not employ an Y p p p Y Y person in such manner as to beco a s'u,,b,,iecntnto or an's Compensation laws of California." Signed '• ` F - ------------------------------------------- Owner By ------- ------------------------------------- -------- -------------------------- ------------ Title --------- -------------------------------------------------------------- (If other than owner) I F .DEPARTMENT USE ONLY APPLICATION ACCEPTED B " __-- ---------------------- DATE ---- 7..10 -�1- - BUILDING PERMIT ISSUED --------------------------------------------------- - ------------------------------- ------ --- ---DATE ------------- ------ - ------------------ - - ADDITIONAL COMMENTS _----------- --------------- -- ------------------------------------- ------------------- ------------ "'� - -- -- ------ " -- --- -- -- -- ----------------------------------fig FinalInspection by- --------------- -�-- - - ----------- ----------------------------------------------------------Date -------!_------------- --- ----, I I SAN JOAQUIN LOCA._ HEA V- H DISTRICT E. H. 9 1-'6B Rev. 5M.