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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 3 S"S 3 Permit No. - -- -------- ------ --�---- ------ ------- ------- -•----- - ------ ------ (Complete in Triplicate i Date issued ----- ��-73 This Permit Expires 1 Year From Date issued . A lication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Pp ' Ordinance No.described. This application is made in compliance with County 549 and existing Rules and Regulations: �-' _ US TRACT ------------------------ JOB ADDRESS/LOCATI - f`��` � �f" f . ------ ----------- ------Phone ------------------------------------ Own ------ -------•-------------------- ---------------------------------------------------- Name _ - --�"� - - f � �_! - -------------------- City _._ .- 691-------------- -------------------•-------- Address -.- .-- Contractor's Name _------------------------------------- ---=------------------------- ------.License # ------------------------ Phone --- --------- Installation will serve: Residence'{❑ Ap artment House Commercial ❑Trailer Court ',❑ Motel ❑Other ------------------------------------------- ---•--- Number of_living,units:-�- "-- Number of bedrooms _____ ___.Garbage Grinder ____".f---- Lot Size - i Private�� 4 ------------ ---------------- ------------------ - s Water Supply: Public System and name ------------------------------------- t r Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loom ❑ Hardpan ❑.,: � Adobe'❑ Fill Material ------------ If yes,type ---------------------V {Phot plan, showing size of lot, location of system in relation to wells, buildings, $etc.rmust be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted f public sewer is available within 200 feet,l V.0 ------ Liquid Depth -------------- 0/ SEPTIC TANK'[ ] : ,5:,. ;��,Size------------------------------ � PACKAGE TRI ATMENT ( ] a -------- Capacity ------ Type ---------------- `` Material ------------------- No. Compartments - ------Foundation ---------------------- Prop. Line -------- Y- Distance to nearest. Veli ____`._>- `--------- ---- s + ^,A` ,. ---- Total Length LEACHING LINE [ I No. of Lines ------------------------ Length of each line ----------------- _De th Filter Material ------------------- --------- � W 'D' Box "-- Type Filter Material -_---------------- p t W f --- Foundation - - -- ------------- Property Line ::=' J Distance to nearest::Well �-�---------�-------- l SEEPAGE PIT [ ) Depth ------------------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No Rock Size -------------------- f WaterTable Depth ------------------------------------------------ 1 Distance to nearest: Well --------------------------------- ------Foundation Prop. Line Date ------------------------ REPAIR/ADDITION ) {Prev. Sanitation Permit# --------.----------------- _ m. - . 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. Home owner or licen. sed agents signature certifies the following: i for which this permit is issued. t shah not employ any person in such manner "I certify that in the performance of the work as to becom b' ct to Wor an" ompensati , ws of California." Signed, --- Owner ----------------- ---------------- --------- ----------- Tit1e t {1f other than owner) FQR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___ ------------ ------------------------------------------- -------------- DATE ----�'- -��-'�''�----------------- BUILDING ----- ----------DATE BUILDING PERMIT ISSUED ------------------------------------ -------- ------------------- -------- -------- ------------------------- -------- ---------------------------------------------- ------=-------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------- ------------- ------------------------------------------ - - ------------ ---------- - ------------------------------------ --------------------- ---- : _ .Date ------------------ Final Inspection by: ___.- - - ------- - - --- -- -- --- -- - - -SAN JOAQUIN.-.LOCAL HEALTH DISTRICT1,�. u n _'AQ RPv AM ''