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--------------------------------------------------- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- ------------- (Complete in Triplicate) Permit ........ ------------------------------- --------------- / 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 County Ordinance No. 549 and existing Rules and Regulations: la JOB ADDRESS/LOCATIONa Gl.J--------- y� p CENSUS TRACT -------------- ----------- K�� Owner's Name .___ ______ ______ __ _ , v -=- ------- ------Phone ------------------------------•----- Address 1 /19--- '- -- -------- -----.----- , 1 - City ---- ---------------------------------- Contractor's NameC License#•o ff-� -r Phone, -:._•..--____-___--- Installation will serve: Residenc11 e Apartment House❑ Commercial :❑Trailer Court ',❑ Motel ❑ Other ---------------- ------------------------- 1. of living units:-----�_:___ Number of bedrooms "_�= :Gdrbagi,Grinder ------------ Lot Size -_ --- Number — Water Supply: Public System and name :. _ _ =m.. . :- ----------- ------ 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 __________- ______________ h (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepdge pit permitted if public sewer is available within 200 feet,) S\ PACKAGE TREATMENT [ ) SEPTIC TANK'[l�'j Size4---x:1�--- --------.............. Liquid Depth's_z------------------------- 4 Capacity _. 1,P00- Tiype ' - - MaterialNo. Compartments _4 --_____________ Distance to nearest: Well ----------S0---------------------Foundation -----1v----------- Prop. line ----59�:--_________ , LEACHING LINE [dj� No, of Lines ________�_____�_ -- Length of"each line--------------------- Total Length ____ s....__.---- i I r� _Depth Filter Material __-___t`f 'D' Box " ---- Type Filter Material -------'----- ----- P -------------------�;---•--=--- f Distance to nearest: Weil ------ _��_C_._r______ Foundation ___gip______________ Property Line, -----} -------------- __-_____-______ Rock Filled Yes No SEEPAGE PIT [ ] Depth ----------------,- Diameter ----- -_�-';-- Number ------ - -- D iQ f Water Table Depth '_ --_ ---------Rock Size -------------------------------- j Distance to nearest: Well ="--------------------------------------Foundation ____________________ Prop. Line _____-------____-___-- 4 REPAIRJADDITION(Prev. Sanitation Permit# _:"`-- --------------- y - Date.------- --' -------.----------1 u 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 Son 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, I shall not employ any person in such manner as to become biect to Workman's Compensation laws of California." Signed -------- --------------- Owner BY ------------ - - --- -- � Title V--------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -- -------- --------------------------- -• DATE _ - ® T ------------------- BUILDINGPERMIT ISSUED --=---------------------------------------------------------------- -------------------------------------DATE ---------------------------------------•--- ADDITIONALCOMMENTS ------------------ ------------------------------------------------------------- ----------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ----- Final Inspection b -_______________Date =: __� -------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT - i E. H.-9 1-'6$ Rev. 5M,