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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --3 -'s— - _ .. - (Complete in Triplicate) 72 ------------ Date Issued __ -a- ------- ----------------- ------------- --------------- ----------- ------- This Permit Expires l Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein k described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. ,r � '- -- US TRACT --- ----- - -----------•- '1 JOB ADDRESS/LOCATI __/�-`-'�_�'�f_L-`-��-- �-------- -'_"-_-I,�C� -- ---� Phone ------------------------------------ Owner's Name - -------------------------------- --- -- --------- - ----- - --- -----�d-.� - --- -- _. City ---1-igO-I-------------- -- -------------------------------•------ Address License # ----- - - ------ Phone ---------=----------•------- Contractor's Name -------------- - i Installation will serve: Residence❑ Apartment House Commercial ❑Trailer Court i❑ i Motel ❑ Other -------------------------------------------- ------ Number of living its ____ Numbe�,.of bedrooms ____ _____Garbage Grinder _____�_____. Lot Size ------------- ----------------------------- U -- - --- - -- -----------••-- s r �.� --•--------------- - ------------------F------------------------ Private Water Supply: Public System and name ___ ___ _______________________ � 5 ti t Character of soil to a depth of 3 feet: Sand'o ;Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ p # Adobe'❑ Fill Material ------------ If#yes,type ------------ Hardpan ❑. 1 t �. (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 publicisewer is available within 200'feet,) PACKAGE TREATMENT { ] [ a... ? Liquid Depth SEPTIC TANK' k , yt Size Type ----------i----e� Material;-------------------- No. Compartments -------------- ------- CapaatY -------------------- YP - 3 Distance to nearest: Well _---: --- ---------------Foundation --------------------- Prop. Line --•----------t------- _-� -...W.. .,_ --- Total Length ------------ ------ Length of each line--=------- 9 �! I LEACHING LINE [ ] No. of Lines ------------- -- g Depth Filter Material Type Filter Material ----------• ------ --------- ---•-•----•----------•----- W 'D' Box ------------ ------- P f _.. - "t -------- Foundation ---------------------- Property Line'_ J Distance to nearest:.Wel! ________________ SEEPAGE PIT Depth Diameter ---------------- Number ---------------------------- Rock Filled Yes E] No G ,� [ ] WaterTable Depth --------------------------------------- -------Rock Size ------------------------------- Distance to nearest: Well -------------------------------------- -_Foundation -------------------- Prop. Line ------- ------- REPA1RfADDITION(Prev. Sanitation Permit# ---------------------------------------------------------------------- Date ----------------------------------) } Septic Tank (Specify Requirements) ----------------------------------------- ------ --- --------------------- - - ---- ------- -- -- -------------------- ----- + , Disposal Field. (Specify Requirements) _-____ �'s~�'"'"= ``'�' /_,� --- --------------=--------------- - ------------------------------- - ------ - ---------------------------------- - {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 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner _ as to becom b' ct to Wor an' ompensati. : ws of California." I Signed Owner ----------------- - --------------------------------------------------------------------- Title --------------- ---------------------------------------------- ------ (1f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --- -- -- - -- ------------------------------------------------ --------DATE -DATE --------��---T,.�----------------------------- --------- ----------------- -- BUILDING PERMIT ISSUED ------------------------ ------------------------ --------- ----------- ADDITIONALCOMMENTS ------------------------------------------------------------------ ------------------------- ---------------------------------- -------- ------------------------------------- _� , Date ------------ -------- - -- ---- -- -------------------------------------- --- Final Inspection by: ----- -- �- - ------•----- ----•`'-...........................------- --------- -- ---- z_ SAN JOAQUIN.LOCAL HEALTH DISTRICT 11A G u 0 1-'AR Rev. 5M