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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT t � --------------- - ---------------- Permit No: -71-- 14.g,s - ---- (Complete in Triplicate) --- - ------------------------------------ t Qate Issued --------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the Son 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. R,. JOB ADDRE55/LOCATION /" l .�'- --- ----------------- -- _ CENSUS TRACT Owner's Name '°/ ------ff �°cb /V1 ----- Phone Address ......' - ' ".-""- -------- = ;�CitY " :',` ''� /J r Phone Z.. 5 Contractor's Name � � - License #r�/ :'' � _ r - Installation will serve: Residence ,Apartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- f Number of living units:----/-1-- Number of bedrooms _Garbage Grinder Lot Size - �•- I t Water Supply: Public System and name - }------------------------------ - ----------------------------------Private i Character of soil to a depth of 3 feet: ' Sand'❑ Silt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpant❑ AdobeX Fill Material ----------__ If yes, type ----------------_--_--____- I (Plot plan, showing size of lot, location iof 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/avaiible within 200 feet,) Il PACKAGE TREATMENT { ] SEPTIC TANK "' Size_ J�iO---_ --/--ft__- Liquid Depth e f - --------------- NJ Capacity - - y e .Material No. Compartments T = ` P -� ------------ to nearest: Wel •-"-- --------------------- - _-___-------_ --Foundation --_ ---------- Prop. Line _--t. ----------- Distance j € i LEACHING LINE No. of Lines -------------- Length of ach line.-e '--- " Total Length4-4741---------- D' Box67_,�r Type Filter Material/,��6e//yDepth Filter Material lW-----------------------_------------ V, --------• ----------- Distance to nearest: Well --- �f-_--_-:_ Foundation -�V------------- Property Line "-------- -I) -=---- SEEPAGE PIT Depth-f--_ Diameter �s---- Number -�"------------------ Rock Filled Yes, No .0 ,� rr Water Table Depth ---- ---------------- -------Rock Size__"`---------------------- Distance -------------- ---Distance to nearest: Well -_ ----------------Foundation -, "----- Prop. Line __0------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank(Specify Requirements) ----------------- -------------------------------------------------------------- DisposalField (Specify Requirements) -------------------------------------------- -------------------------------------------------"---------------------------------- # ------------}------- v------------------------- --- k ------"----------------- --------- - - - - - - -----------------------------------------------:--------------------------------..-----------------------.---------------- (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: t "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 o r than owner FOR DEPARTMENT USE ONLY k14 1 i APPLICATION ACCEPTED BY - ---- -- --- ------------------------------------------------------------ - DATE __f0_`_ - ~ BUILDINGPERMIT ISSUED -------------------------------------- -------DATE ------------------------------------------- ADDITIONAL COMMENTS -- ----- ------------ ---------------------------- ---------------------------------------------- - - ---- ----------------------------------- ----------------- ----------------------------- ---- ------ -- ------------------------------------------------- ------------------------ ------------------------------------------- ---------------------------- --------- - ----------------------------- --------- -------- ------------- ----------- - Final Inspection by: _ -- -- - Date --1�--------�-�-----------"- -" - -------- --- -- - -- -- - - - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT y ,} ., E. H. 9 1-'f 8 Rev. 5M