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FOR OFFICE USE: -`--------------- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Permit No. Date Issuedl---= Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describedII 7Thi sappliiccation is made in compliance with County Ordinance No. 549 and e" isting Rules. and Regulations: ; � RACI _ NJOB ADDRESS%OCATIOkS �c3,& _040ENSUS TIlls��31_ ,D0 Owner's Name t------- VcQ Ja------------- ----- I -------Phone ------------ Address -- ------ Address ---------- ------------------------------------------------ city ---- 1------tem--C---------- Contractor's Name ---- --------- --------License #�.-_--- Phone -./'--- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑Trailer Court i❑ j MotelOther Awbil..-�1)7-e---- Number of living units: ____--- Number of bedrooms --- � ---- Garbage Grinder ____---- Lot Size -_----------------------------------------- �I Private 1 Water Supply: Public System and name ------------------------------------I Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ PeaX Sandy Loi` m ❑ Clay Loam.E] Hardpan ❑ Adobe.l] Fill Material ------------ If yes, [Plot plan, showing size of lot, location of system in relation to- wells, buildings, etc. NEW INSTALLATION: (No septic tank or seepage pit permitted if Public sew,eer� is availa PACKAGE TREATMENT [ ] SEPTIC TANK Capacity/070-Q---,-- TYPepile- Material_ �� ------ i Distance to nearest. Well -�Ql�----------------------- Foundation ___� LEACHING LINE No. of Lines ---------c --- Length of each line -- 0-2-7 --- ----- Len �',,tt,,,,- -----:i 'D' Box --- /----- Type Filter Material _ QC --Depth Filter M Distance to nearest: Well ,D_0--- ---- __---- Foundation _---------. SEEPAGE PIT f ] Depth ------- - ------------ Diameter ------------- -- Number ---------- ----------- 1, S' Pe--------------------------- ust be placed on reverse side.) le within 200 feet,i ___ Liquid Depth ---- -------------------- o. Compartments ---- ...... Prop. Line Total Length X-27 - A/ terial8-------- •----------------- .. ---- Property Line---•-•-•-�-.• __ Rock Filled Yes ❑ No Water Table Depth Roc ize-------------------------------- Distance -------- ------ - ----------------------------------------------- jf - Distance to nearest: Well ------------------------------------- -Foundation ----- -------------- Prop. Line ---------------------- REPAIR/ADDITION (Prev. Sanitation Permit #-------------------------------------------- Date--------------•--I�-----------• ] Septic Tank (Specify Requirements)------------------------------------------------------------D--- ----- IM -------- -/,� Disposal Field (Specify Requirements) ------- �'�? ----------------- --------------------------------------------= -- -----------.---------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) certify that I have prepared this application and that the work will be don in accordance with San Joaquin I hereby fY t 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 certify that in the perforrnance of the work for which this permit is issued, I shall not employ any person in such manner as to be 4siect'to ork n's Compensati n laws'of California." Signed ---------------- --------------- ---- Owner ------------------- ------------ Title ----------- ----- ------------------------------------------ ----------- (If other than owner) �-JTOR DEPA TMENT USE ONLY APPLICATION ACCEPTED BY - ---------�--- -------------------------------------- 1I--. DATE _%1� /----0- --------------- BUILDING PERMIT ISSUED __'------------------- ---------------- ---------- ------------------------------------------ �I. ---- DATE ----------------------- !1- --------------------------- ADDITIONALCOMMENTS - -`--- ----�--•--------------------------------------------------------------------------------- - % S _ ____________________________ a ________________________________________ y___________________________________________________________________________h____---_-_.__________-__________--__________________.__._ ___ ________ _ ____ _________________________ f__ _ -_ ___ _ _ _---------------------------------------------- ____-------- - _- Final Inspection b //-____ Date --_/ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M. r ,