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FOR OFFICE USE: PPLICATION FOR SANITATION PF".IT b., J k Permit No. .��_�� (Complete in Triplicate) --------- ---------------------- - -- ----- ----- .• --• --- --------------- This Permit Expires 1 Year From Date Issued Date issued v i Application is hereby made to the San Joaquin Local Health District for a per 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 J72. ✓.-hi1 .,::_..-,:/c�•' =" ===6`"------------- ,11 --------- ---CENSUS TRACT -------------------------- Owner's Name,4;1,, �c �ro✓_�/ �U' ��` _�° .�� -� Phone Address _ _�_!r _:� �--• ,--------' � ' , -- ------------ --------- City � - yY��_ ------------------------------------- Phone - Phone ---_------- ----•---- -----Contractor's Name ------------ --� -.License # Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -------------------------------------------- Number of living units------------- Number of bedrooms ____-_...__.Garbage Grinder ------------ Lot Size ________-___________--_____-_______-------. Water Supply: Public System and name - ---------------------------------------------•-------------- ------------------------------------------------Private 2r, " Character of soil to a depth of 3 feet: Sand'❑ E] E] EDSilt Clay Peat Sandy Loam .l�Clay Loam ❑ i Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- IPlot 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) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----------------------•------------------------- Liquid Depth ------------__ --_---.----- Capacity -------------------- Type ------- ------ Material---------------------- No. Compartments ----------•----- Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line .__-_________ ........ LEACHING LINE [ ] No. of Lines _______________________ Length of each line__ ------------------ ------ Total Length :----------___.________ 'D' Box _...---- -- Type Filter Material ------•-------------Depth Filter Material --------------------•---------------.-...... i Distance to nearest; Well _.---------------------- Foundation ------------------------ Property Line -----------------_---- SE EPAGE ___________SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---- -------------------------------------------Rock Size ------------------------•------- Distance to nearest: Well --------.--•----------------------------Foundation --------•----------- Prop. Line _.-------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------i------------------------------------- Date --------•-------------------------] [Disposal Field (Specify Requirements) �� C. =' -= _ ----------- Se tic Tan (Specify Requirements) _._-_ ----------ono....... - ._ /�,_;. ------------------------------------------------ -------------------- V-------------------------------------------- ------------ --- ---------------------------------------------------------------------------------------------------------------------•--- ------ (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 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 subject to Workman's Compensation laws of California." Signed ---------------------------- ! -------- Owner ----- F-title ...._ rLa_ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...r:, -------------------•----------------- ------------------- --. DATE _- r -------, j BUILDING PERMIT ISSUED ------------------------------------- ---------------- -------------DATE ---------------------------------------- -- ADDITIONALCOMMENTS ---------------------------------- --------------------------------------------------------------------------------------- -------••-------•- • --- I ------------------------ ------------ --- ---- i ------•------ --- ----- ------------------------------------- ----------------------------- - ------- ------ -- ------------------------------ Final Inspection by: ------ ---------------- ------------ ----------- ---------------------Date SAN JOAQUIN LOCAL HEALTH DISTRICT ' E:H. 9 1•'6$ Rev. 5M