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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- ------------- ------ Pe � (Complete in Triplicate) Permit No., _ ______________ --------------------------------------- --------------- This Permit Expires 1 Year From Date Issued Date 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 ou ty Ordin nc No. 5549 and existing Rules and Regulations: i JOB ADDRESS/LOCATIO �Q- -1 -�-- -- _ _ --- ------------ ,141617-CENSUS TRACT --�--��-- - - -- Owner's Name -,- --------- ----- ------------ - ---Phone _�� _`I_tA b- --- -- ---- --- --- --- ----- --- ---- n AddressQ - ------------ l City -- - ----------------------------------------------------- ------- /, G Contractor's Name ------- ------ ---- --- -.-.License #�+ .-JC�/-- Phone Ta_'_ f&_ _. Installation will serve: Residence ❑Apartment House C mmerci I:❑Trailer Court ;E]Motel E]Other _ _ __ Number of living units:-___1.__-__ Number of bedrooms _-_Z—Garbage Grinder ------------ Lot Size ---------- Water Supply: Public System and name ---------------------------------•-----------------------------------------------------------------------------'Private Character of soil to"a depth of 3 feet: Sand[] Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ i Hardpan ❑ Adobe X Fill Material ____________ If yes, type _______________________f____ (Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must.be plated on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if pubic sewer is available within 200 feet,} "'-C/ �� 0 i PACKAGE TREATMENT SEPTIC TANK Size___._ q p s { ] -A--/�_:---- � -------- Li uid De th -.--am--- - Capacity �_ �__ _ifType A�_L+/ Mafierial-__ j'1•G._._ No. Compartments -------- Capacity Distance to nearest: Well _______________Foundation_./Q Prop. Line ___.------- LEACHING LINE No. of Lines ____-_ ----- -- Length of each. line.____-� __ _________ Total Length ____�r�_._...__._. 1V . D' Box _105 Type Filter MaterialDepth Filter Material4S- -r ------------- Property Line ________________________ V* SEEPAGE PITT Depth ___ Diameter -_`73 ______ Number _,--------------------------- Rock Filled Yes V No i❑ Water Table Depth ------------------------------------------------Rock Size /4� -- `--'-- '?'------ a Distance to nearest: Well --/ f` ___....Foundation 1--�-� _ p. �� ---- --------•----- -�-------- Pro Line ---------•--------- - REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) SepticTank (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 1 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 performance of the work for which this permit is issued, i shall not employ any person in such manner a as to become subject to Workman's Compensation laws of California." i Signed ---------------------------- -- -------- Owner -- -------------- ------------------------------- BY ------------ Title -------------Pat,- --------- (If ------- - ,---------- (If othe t an owner) FOR DEPARTMENT USE ONLY --3 - �7 APPLICATION ACCEPTED BY ---�`� ' --------------- -------------------------------------------- ------------------------ DATE ---�------------------- � BUILDING PERMIT ISSUED ------------------ --------------DATE -------------•--------------------- ADDITIONALCOMMENTS ----------------------------------------------------------- ------------------- ---------------------------- --------------------- --------------------------- ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ---- - -- --------------- ------- -- - --------------------------- ------ ----- ------------------------------------- - -- - ------------------- --- - --------- Final Inspection by: Date _. '--. -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M '