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FOR OFFICE USE: APPLICATION F+bR SANITATION PERMIT 1 - (Complete iTriplicate] ' en � � Permit No. ------ --------------------- - .-.--__--- This}f 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _�� ry ---- ----------------------- '`- -.Z�� CENSUS TRACT Owner's Name - ----Phone -------------"_-_-- Address a-Ij� 3 Cit --- ----- - - -- ----- O / " Contractor's Name -----_----- "--_ --------- _-.,".License # �� ° - Phone ----------------------_ Installation will.serve: Residence Apartment House❑ Commercral ❑Trader Court i❑ Motel ❑ Other ------------- -"--- - Number of living units:---.- ___ Number of bedrooms ------Garbage Grinder ------------ Lot Size Water Supply: Public System and name --------------------------------------------------------- -----------------PrivateA Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay, ❑ Peat[] Sandy Loam [] Clay Loam ❑ Hardpan Adobe ❑ tfill Material ,--_--.-.-- If yes, type ---___---------------" (Plot pian, showing size of lot, location of system i.n relation to weils, 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 !X / Size' --------- Liquid Depth ----------- Capacity "-� ype�-- _� Material"__ ""- No. Compartments Distance to Weare Well _-"-"--__ D � -------------- .../P1---�- - Prop. Line " '_ -__________ ( No. of Lines ---- ------ ---------- Length of each line-- --�0./___---__-- 10 LEACHING LINE f- - Total Length -_�0"�_________________ 'D' Box . _ r.1. Type Filter Material "_- ��_ ____Depth Filter Material ---- -- Distance nearest: Well __.". _---__---- Foundation --------1.0---------- Property Line c.7-_--__ ------------- SEEPAGE PIT { Depth ---� _f_----" Diameter r~ "_"-"�`-""""-_ Number _______ -______ Rock Filled Yes 8-/ No i❑ Water Table Depth -------------5_-----------------------------Rock Size Distance to nearest: Well __".---4 ()! ------------------------- --- _!�-"�__""""_ Prop. Line -"" __"_" REPAIR/ADDITION{Prev. Sanitation Permit# ""-_ "".""___""""---__ -.-_-- Date --------------- ----------- Septic Tank (Specify Requirements) ------------ ------._ - ------------------------------------------------ Disposai Field (S eci yRequir ments) ---------------"-_-_--"""------------------ ------ --- -------- -- ----------- - ----- --- ---------------------- (Draw existing and required addition on reverse side) f hereby certify that I have prepared this application and that the work will be done in accordancewith Saiz 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, f shall not employ any person in such manner as to bec me ubject to Work an's Compensation laws of-California." Signed -._ --- ------------------ - --- -- -- -------- BY - - ------------ Title -: G ------------------- (If other than owne FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ - --- -- -------------------------------- ------------- -•---•---------.". DATE ------------ BUILDING PERMIT ISSUED --------------------- ------------- -------------- DATE ADDITIONAL COMMENTS --------------_____________ - - - ---------------------------------------------------------- ------------------------------------ ----------------------------------`------------------------------------------- Final Inspection by: .-. = -- --------------------------- Date ." -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 , 1268 Rev. 5M • � A