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FOR OFFICE USE' ---- APPLICATION FOR SANITATION PERMIT ----------------- ---------•- Permit No. ------------------- (Complete in Triplicate) This Permit Expires 1 Year From bate 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 Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION � s"s_v__ -'---- ---- - -------------4°tIH -�--CENSUS TRACT --.---- -. ` I Owner's Name - ----- -- -- - --�Q------------------------_---------- -__.._.Phone��- _ ------------------ -------------------- ..__ ' Cit `�- Address _f�_//S la----- -- #t.AA7 '- Y f Vit: ----- Phone Contractor s Name _ -- --------•�------.License # -�!) Installation will serve: Residence ❑Apartment House-E-] Commercial.❑Trailer Court ,❑ Motel$Other __._._ Garbo /DC7 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❑ Clay ❑ Peat❑ Sandy Loam Clay Loam.0 Hardpdn"❑ Adobe'❑ Fill Material t4_0_-_-= 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 I ] SEPTIC TANK Size_ ----------_---------___ Liquid Depth ------�.-------- Capacity (p d----____ Type/ _____ Material- No. Compartments ------_----------- �.. , 44 Distance to--nearest: Well _____I.Qa____________________Foundation ----- --- Prop. Line __ ...--_____-----__ LEACHING MqE No. of Lines Length of each line.-r .4__ _r _o- ---- Total Length ______-____________________ 'D' Box Type Filter Material S` > .Depth Filter Material __-��_______________________________ s 1 ---I D------------- P operty Line •S � " ' Distance"�o"nearesfiWell --��------------ Foundation - Diameter Number ___.___--.-_ - _ Ro)k Frilled Yes No .0 SEEPAGE PIT [ ) Depth --------------------� ---------- ti ❑ Water Table Depth ------------------------------------------------Rock Size ----------I-----------1--------- Distance to nearest: Well ----------------------------------------Foundation- ---------------.----Prop. Line ----------------,.-•--. _: REPAIR/ADDITION(Prev. Sanitation Permit#-------------------------------------------.- Date -----------A____-___--------..----I Septic Tank (Specify Requirements) ------------------- --------------------------------------<-----------------I---------- , Disposal Field (Specify Requirements) -j______r ------------------------------ -- ---------------------------------------------------------------- - __.. ------------------------------- ------ ----------------- (Draw existing and required addition on reverse side) "+ I hereby certify that 1 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 Distrpct. Home owner or liven- 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 or an's Compensation laws of California." ` Owner Signed --- ------- BY --- ------- ------ ------------ , Title (If other than owner) r FOR DEP ENT USE ONLY APPLICATION ACCEPTED BY ---- `---------------------------------------------------------- DATE ___ 1_�-- _` '- ---------------- BUILDINGPERMIT ISSUED ---------a-------------- ----------------------------------------------------2---------------------------DATE -----------------------------------------.. ADDITIONALCOMMENTS /- --------------------------------:---------------------------------------------------------------------------=--------------------------- - -------------- ----- ----------------------------- ---------------------------- -- - ----' -------------------------------- fi /------------ - k ; - ' ¢� Final Inspec i 1 ----------------------- ----------------------------- Date, ' SAN JOAQUIN- LOCAL HEALTH DISTRICT t, E. H. 9 1-'b8 Rev. 5M