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FOR OFFICE USE: .PPI.ICATION FOR SANITATION PERI C ....-- / -------------------- --------------- W (Complete in Triplicate) Permit No: _.7-r---7- -- 7 --- -------------- -- - -- - ------.- p This Permit Expires 1 Year From Date Issued Date Issued - -------------- u 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: JOS ADDRESS/LOCATION .--- - - ------ - -f- --------------------------------CENSUS TRACT -Z----.---------- Owner's Name --- 'ei-- Phone u City -Address . Contractor's 3yS Name _.� --- w___ la !"--- ars license # .d,'_ ,_ Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailei•Court Motel ❑Other ----------------- -------------------------- Number of living units:---/------ Number of bedrooms _--- .n Garbage Grinder ------------ Lot Size --_ R _�- --------- Water Supply: Public System and name -- ----- -------------------------- ---------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam LJ Hardpan g] 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,) ! PACKAGE TREATMENT [ ] SEPTIC TANK* Size----�'�•_-��---��-------------------- Liquid Depth ---- -------------- Capacity Type �rxA rs�_ Material__. y�:r4'No. Compartments' -- ------------- Distance to nearest: Well .-.___- -- ----------------Foundation __-- - Q-------- Prop. Line --- ----------•_---. LEACHING LINE 41 No. of Lines .__ — Length of each line----- Total Length , � �F 'D' Box . -' . . Type Filter Material /--''&-__-_-__Depth Filter Material __. r • i D--sstance to nearest: Well ------ Foundation (-- -- ------------- Property Line. ;4---------------------- 2 -_---________. __ SEEPAGE PIT j, Depth �-- --._- Diameter 3_�_ --__- Number --- r7-.4._...-�__.____ Rock Filled Yes t No 3❑ Water Table Depth --- ------------------------------------Rork Size -- i --------- "' Distance to nearest: Well ---------------------Foundation ------- Prop. Line - -------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------------- -------------- Date ----------------------------------) SepticTank (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 w 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 BY --------------------------------------------------------------- --- -------------------- Title ------------- - ------I--------------------------------- --------------- v (If other than owner) FOR DEPARTMENT USE ONLY .-. - "�"�-`��`'_'-_-._ - ---- . DATE -. 4------ 11 e ---F---------------- -- APPLICATION ACCEPTED BY L.& BUILDING PERMIT ISSUED ----- -------------- ---- ---- ------- ---------- ---------------- -------------------------------DATE -------------•----- ----------------------- ADDITIONALCOMMENTS ----------------------------------------- ----- -------------- ------------ --------_-------------------- -------- ------------=--- -----_------------ ---------- ------------------------------ - --- -- ------------- ------------ - ----- --- '= Date; .._ �`" ' /� ----- -- -- --- Final Inspection b r'/ - SAN JOAQUIN LOCAL HEALTH DISTRICT U4 E H. 9 1-'S8 Rev_ 5M