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-1 +m V1 7 ll.0 Vic: APPLICATION FOR SANITATION PERMIT 5� -- (Complete in Triplicate) Permit No. __ S• 7 ---------------- This Permit Expires 1 Year From Date Issued Date Issued ___l__- ------- Application ----7Application 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 -- . /. 1 __.-- ---- Q t f4 '. _._CENSUS TRACT ................. Owner's Name _- C.--� r�, (� -- ---•---•--- ----•- -- •----.._.... one T'YJ - f--�4�---- Address � --- Contractor's - City - �L � - lL�/ l Contractor's Name --- - `-- -------------------- ------------ /�t?-Z_. T ------- Phone .-- ---------- Installation will serve: ResidenceKApartment House C] Commercial ❑Trailer Court I❑ Motel ❑Other--------------------------------- of living units:_-___ -_-__- Number of bedrooms -----Garbage Grinder ------------ Lot Size ...-_Z. ,-_________ Water Supply: Public System and name ----------------------------------------------------- --------------Private Character of soil to a depth of 3 feet. Sand L] Silt Q- - Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe 'Fill Material .----------- If yes,type_------------ -------- (Plot plan, showing size of lot, Iocation of system in relation_ .o wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit ¢ertnitted if public sewer is available within 200 feet,) PACKAGE TREATMENT` [ ] SEPTIC TANK i ] 1I-Size---------------------------------------------- Liquid Depth --- ----------------------- . Capacity - ------- Ty le ----------i------ Material---------------------- No. Compartments -Qistance to nearest: Well ......_-__----. _-- •--._._.Foundation ------_ Prop. Line ----------------------J LEACHING LINE `F ' [ j kNo, of lines - ----__._.___..,a` Leng of each line-------- ... -.-_. ._.-_- Total Length W f D' Box --------- . Type Filter Materi�l --------------------Depth Filter Material - ----- ___ . . -•-_---•------------- 6 Distance to nearest: Well -----------.............. Foundation _-__.__.-._ ---------- Property Line _.---_------____--__ SEEPAGE PIT [ ] Depth -------------------- Dkiame}er ................. Number ------------ ---------- Rock Filled Yes ❑ No Q WaterTable Depth ------ ---------------------------------------Rock Size --•-------- ------------------- Distance ------- --- ----- Distance to nearest: Well _.--------------___:.__.______---------Foundation -----.------------._ Prop. Line .- _1--_.--.:__-� REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- ----------------- Date --__._---___--_•••.-_-----.•-_-_._) Septic Tank (Specify Requirements) ----- ----------- ---------- -------- Dis osal Field S ecif Requirements) - - - --- - , . , - -----------------------------_--- ---- (Draw existing ------and required addition on reverse side) I hereby certify that I have prepared this application and that the work wilt 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." - y, Signed ._ ------ Owner BY - i - -- - Title _. - - - othe_r t n owner) FPR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _...... ....... DATE .._ - -------------------------------- BUILDING PERMIT ISSUED _.. - - -- ------------ DATE ADDITIONAL COMMENTS -. . ------------ ------------------------- ------------------- - -- - ------------ ------------ Final --- --- --- ---- - -- ---J / Final Inspection b Date --------- Eli 13 211 1-613 Rev. 51�i SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M