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FOR OFFICE USE: APPLICATION-FOR%SANITATION PERMIT - - - - - --------"-----•- - Permit No. (Complete in Triplicate) OV --- --___"-----------------___."______--_______---.- This Permit Expires 1 Year From Date Issued Date Issued -__ 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 Ordnance No. 5�4y9 and existing Rules and Regulations: JOB ADDRESS/LOCATION.------— ---"---- -y --------------------- ------------------------- ---- --------- CENSUS TRACT Owners lame" :.. '�/ F ' ;1� ✓ J! Phone '°------------------------ -- r •-.... Address " �. . 4t� -----`---------- city ------` ---------------- -------------- --------------------••-------- Contractor's Name -------------------•-------- ---------------------------------------------------------License # ------------------------ Phone ----------------------------- Installation Willi 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 ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt F] 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.) 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 j,'' j=------- Type -------- Material �,._ No. Compartments Distance to nearest: Well _R__ r------------------------Foundation ---1.0------------- Prop. Line ---------------• LEACHING LINE No. of Lines ------------------ Length of each line--------- "1z-` Total Length -___ ---------- 'D' Box Type Filter Material ------------------------Depth Filter Material ------- Distance to nearest: Well _____-_o-------------- Foundation ----{_,_`---------_-_ Property Line ---='__------, -_. SEEPAGE PIT [ Depth ---_;�-- `_ --_ ____ __________ Number ------_�___--.----_--____ Rock Filled Yes � No Diameter �, 0 Water Table Depth -: �------------------------------Rock Size -----7 '-- ----`---------------- Distance to nearest: Well _______ ---------------------_-Foundation ........o .______ Prop. Line ......''._,.__--_--_ REPAIR/ADDITION(Prev. Sanitation Permit#----_._--_ _ .I_- �. -------------- Date ----------------------------------) Septic Tank (Specify(Requirements) ----- ------------- - ---------------- - - --------- ---------------------------- ---------- - ----------------- -- -------------------=--------------------- ,. Disposal Field (Specify Requirements) ._.__" " _____________________ . _-_-- .�" ---"---- ---- - (Draw existing and required addition on reverse side) 1 hereby certifygthat 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 Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the followin4: "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 -----= r�"�' �` - t--------------------------------- Owner By ------ --------------- Title . •(If other than owner) �.' FOR DEPARTMENT USE ONLY APPLICATISJ� ACCEPTED BY -" `" =':,=- --------"----------------------------------------------------------------- DATE _''n.f = ';r BUILDING,- E T ISSUED -------------------------------------- - ---- -------------DATE -------- -------------------------- ADDITI0IjAMMENTS ---------- --------------------------------------------------------------------------------- ------------------------------•---------------------------------- -� ------------------------ ------------d> -------------------------------------------------------------------- -------------------------------------------------------- -------------------------------- - -------- -" ---- -------------- ------ -- -------------- _ Final Inspec io by: - _Date - �' �,� -- --------- SAN JOAQUIN LOCA HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M 4..