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FOR OFFICE USE: APPLICATION FOR SANITATION PE IT ----------------- -------- f' Permit Nora l 1 (Complete in Triplicate) This Permit Expires 1 Year From bate 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: JOB ADDRESS/LOCATION '--�C--N--- - --- ---- - -l"-..�,�_-`G.W------ ------------------------------CENSUS TRACT --------------..__-------- Owner's Name --------------------------------:----- -------------Phone Address ---------- _.3. 3---------- ------------------------- City Contractor's Name ----- s.er�--- ---- �r- � --�---- ---License # �d ' r?'_. _ Phone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ------------------------------------------- Number of living units:--- f_-_- Number of bedrooms ____.Garbage Grinder ------------ Lot Size ---.---- Water Supply: Public System and name ----------------------•----------•_------------------------------------------------------------- ------Private (o Character of soil to a depth of 3 feet: Sand b Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 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.) Q, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC-TANK 1 Sizr / -/�'-��----��'�---------------------- -- Liquid .Depth -�---------------....-- Capacity(__.g�7_a__`�_ Type -� Material__ No. Compartments c�-__-_'_-_____. Distance 'to_nearest: Well -----------`•_�- -----------------Foundation ------>U__'.------ Prop. Line ------9 --. ---.---- LEACHING LINE No'. of Lines C [ cam______________ Length of each line.- r0--/--------------- Total Length ,_fir'-�_---- 'D' Box ___ __. Type Filter Material ----�5,_ _s------Depth Filter Material -_/I--------------_________________________ Distance to nearest: Well __ Q_-_-------------- Foundation ---- Property Line. ______________________ \ SEEPAGE PIT Depth __._- _S______ Diameter ---------------- Number ____/__�_ ---------- Rock Filled Yes No Water Table Depth ----------------�42-p 1--------------.--•_Rock Size __ _ .. Distance to nearest: Well ------- ----------------------f=oundation ----- 4_E---t---- Prop. Line ------'-----:_.._-....... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- Septic ---------------------_----- -----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 owneror 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 beta subject to Workman's Compensation laws of California." Signed -------------------------- -- --- ----- ---------- Owner BY -- -- - Title - - - --------------------------------- '(If other than owner) FOR DEPARTMENT USE ONLY --------------- -- •------------------- -----. DATE ` . APPLICATION ACCEPTED BY__.� _ _ _ _ _ _ _ �_____ _ __ ___ ----_ --- _- BUILDING PERMIT ISSUED ------------------ -------------- -------------- ----------DATE -------------------------------- - ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------- ------------------ --------------------------------------•--------- ---------------------------------------------------------------------------------------------------------------------------------------------•------------------------------ -- - ------ ----------------------------------------------------------------------------------------------------- ----------------- - ------------------ -- ------ - - - ---------- --------------------------------------------------------- ------- Final Inspection by: ------- --------------------------- --.Date � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M