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4 ' FOR OFF.lC,E USE: APPLICATION FOR SANITATION PERMIT - - ------------------- -- [Complete in Triplicate) Permit o: ---------------------- ---------- -_.................. ---------- ----------------------------- ---- This Permit Expires;] 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 . ___�____ 2�1__ `_ _ .___- __ l e `" /--------CENSUS TRACT ___---_-------____-------- Owner's Name -------- -- -------------Phone .-.,3 -- - 9-3-1/0 �� Address ----------------9-3--1/0----------!vi ff ---I----------- � City = Contractor's Name ---------------(/4(A-,V7A------ --------------------------------------------License# --------------- --------- Phone ---------------------------•-- Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court X • I Motel ❑ Other ------------------------------------------- Number of living units:------ --- Number of bedrooms _--_�-Garbage Grinder ._______-___ Lot Size _- Water Supply: Public System and name --------------------------------- ----------------------------------------------------------------------------Privatex Character of soil to a depth of 3 feet: Sand,'[] Silt o Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan Adobe '❑ Fill Material ------------ If yes, type ____________________________ I (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,) [ ]p Y '�'----------------- TYpe ---- ------- ------- Material- --- --------------- Liquid Depth --------------------------- Capacity ------------------------- PACKAGE TREATMENT SEPTIC TANK Size_______________________________--_.------------ Ca acitNo. Compartments ______________________ M) Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------_---.-- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _________-____--------_-__ m 'D' Box --__ ------- Type Filter Material ____________________Depth Filter Material --------------------.----------------------- Distance _______------ . -_._Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _______________._...... SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ----------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -----------------------.---- -- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ._.......-...... 1 REPAIR/ADDITION(Prev. Sanitation Permit# .... __ ._ _ `!____ Da)_________ ________ h Septic Tank (Specify Requirements) -------------- -- ��-- -�'-- -+f~----------- i Disposal Field (Specify Re uirem '`__ents} ___ ___ --C _ _ 1 --------------- ---------------- ----------------------- -------------------------------------------------------------------------------------------------------f/ ---------------------------------- ---------------------------- --------------------------- --------------------------------------------------- --------------------------------------------------------------------------------------------- 1 (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 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 - ------------------------------------------------- ----------_----- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- -------- BUILDING _________________- DATE _—9-/5?-1713__-- ----------------------------------------------------- _ BUILDING PERMIT/ISSUED ---------- DAT r'!��'} - ADDITIONAL __ . /D` _2" �' ----------- ------ --- - ------------------------------ -------- -- ----- Y -- - --- -- --- -- - ------- - - - ----- - - - - --- --- -- -- ------ ---- ----- - -- --- ------- --------------------------------- ---------------- --------------------------------------------- ---------------------- - --------------------------------------------------------- --------------- FinalInspection by: ------------------------- ---------------------------------------Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M