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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit o_ ______________ __ ----------•------------------------------------- -.:^,. ,� --------- -- -- ?his 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.X54/99 and existing Rules and Regulations: JOB ADDRESS/LOCATION .- 4- alb - NSUS TRACT -------------------------- Owner's Name ---_--- -- - ,./ - - - ------ --------------- --------------------------------------•------------ ------Phone --------------------------------•-•- Address ---- --7- -- - -- - �2 � `--------------- City ----------------- --------•---- - --G-------------------------------------- Contractor's Name ---__ ---.License # _177P_"__ Phone ----_--___------------------ ' Installation will serve: - Residence [!�'partment House,❑ Commercial :❑Trailer Court ;❑ � t Motel F1 Other - ---------------------------------------- Number of living units:.--------- Number of bedrooms _�2,.__Garbage Grinder 1'k.-I--- Lot Size __ --------------- Water Supply: Public System and name ----------------- --•-----------------------------------------------•-------•---------------------Private [ 1 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ET--- Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---__--_--___-__-___---_ (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 public sewer is available within 200 feet,) V PACKAGE TREATMENT [ J�j SEPTIC TANK'[ ] Size--------,_k6 x-5-_--------------- Liquid Depth -- *L 4 Capacity 0 �Q Type Material-_ Noy, Compartments Z--------_----- r ----------- prop. LneDistance to ne st: Well --------t-,-.5- - --s------------------ i LEACHING LINE No. of Lines __ __-- -_-- Length of each line--- ------------------ Total Length 'D' Box •!►'kt -- Type Filter Material' 17 ----Depth Filter Material 1_r----------- -------------- ---- A rWell ;-s--------- Foundation _��--`------------- Property Line _ ------------- e; s SEEPAGE PIT [� Depth �-��est. Dfameter ___ Number ----- -- ----------------- Rock Filled Yes E�r No .0 Water Table Depth 60 ----------------------- Rock Size Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------.-.-----__ REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- ------------ Date ----___--------------------------) Septic Tank (Specify Requirements) ---------------------------------------r----------------------------------------------------------------------- ------ Disposal Field (Specify Requirements) ---•------- --------------------------------------------------------------------------------- ]i ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ? ------------------------------------------ - - - - - ------------------------=--------------------------------------------------------------------------------------------- (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 cerci that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to beco subject t Wor man's Compensation laws of California." Signed t Owner ------------ --------------------------------- By - ------------------------------------------------------------------------------------------- -Title ---------------------------- ------------------------------------------- (If.other than owner) FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY ----- .f--------- - &�-------------------------------------------- DATE � -- --------------- ! BUILDING PERMIT ISSUED ------------------ ---------DATE --------------- --------------------------- ADDITIONALCOMMENTS ---------------------------------- ---------------------- -- ------------------------ -------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- -----------•-------------------------------- ------------- -------- =------- � - ----------------- --- - ---- --- -- - Final Inspection by: ---- - ------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M