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a`t PLICATION FOR SANITATION PIMA ----- --- Complete in Triplicate) Permit No. ---- 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 eiinn compliance with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS LQCATION .; � - --- -= -- - �'' ---------------�---------�-- � =_� R ------------------ CENSUS TRACT -------------------- Owners ------ ------------Owners Name ------" -_A ------------------------------- . ------Ph one ------------------------------------ Address - ---- ------- ----•---------------Address ------------- , . _ ------------ City =.- _ = --- --=--------------------------•------ -------- Contractor's Name = =1 ----1 _6_t-=- -I--- ------.License # �� .i`�- f hone Installation will serve: Residence ❑Apartment House❑ Commercial:❑Trailer Court ;❑ Motel ❑ Other --------- ---------------------------------- Number of living units------------- Number of bedrooms _________--Garbage•Grinder ------ ..... Lot Size '4-f..)Z-4L_ _ ________---_-_________- Water Supply: Public System and name ----------------------------------------------------------------------------------------------------------------Private 0................... Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay E]_ Peat E] Sandy Loam ,0 Clay Loam 0 Hardpan 0 Adobe [;_FillyMaterial ------------ If yes, type ---------------------------- (Plot plan, showing size of lot, location of system in relation to wells,,;bwildings, etc.`muni t be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) D PACKAGE TREATMENT [ } SEPTIC TANK} } Size------------------------------------------------ Liquid Depth ---_-------------- Capacity ------ ------------- Type -------------------- Material---------------------- No. Compartments ------................ Distance to nearest. Well ------------------------------------Foundation ----------------------.Prop. Line __-- Ilk - LEACHING LINE [ ] No, of Lines ------------------------ Length of each line-------------- Total Length 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- ------------------ Distance to nearest: Well _______________________ Foundation _-____-----_-___-_--__- Property Line .-�_____-_---____-_-_-___ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled • Yes '❑ , No !❑ E Water Table Depth ------------ ----.--..Rock Size --------------- i j i Distance to nearest: Well -----------------------------------------Foundation -------,------ =-- Prop., Line ............----------- E REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date `---_------_----------------____-} i Septic Tank (Specify Requirements) ------------ ----------------------------------------------- -- =' - ,< --------------------- OS DispY Field peafy R quire t 4 i - -__ _. -------------------------------- z___-_____ _"______ _ __________________________________-_______-________-_-_-_________v__---__-____________---- i ---------------------------------- ---------- ----------------------------------------------- ___________--__-_______'__.___________-_________- �___________ __--- _-___ _--------- X - __ (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. Horne owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this peirnit is issued, I shall not employ any person in such manner E as to become subject to Workman's Compensation laws of California." Signed fi ---------------------- ..�...�% (I -------- ------ If other th� caner] t' -- - I FOR DEPARTMENT USE ONLY - � - APPLICATION ACCEPTED BY . � ----------------------------------- ----------------- DATE - BUILDING PERMIT ISSUED . `--'---- -- ---------- ----DATE -------------•-------- ----------------- ADDITIONAL COMMENTS ---------------_ --------------------- ------ 1 ---------------------------------------------------- -------- - - - - -- ------------------------------------------------------------- ----------------- --- ---------- ------- ------ Final Inspection lay:- - Dated__ ------_ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'Sa Rev. 5M