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FOR OFFICE USE: w , APPLICATION FOR SANITATION PERMIT Pit N7�_S7� Permit o. (Complete in Triplicate) - �E ---------'---------------------------------------------- __________________________ This 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/LOCATIO �� /_:-- - A----- ---------- __. ------CENSUS TRACT -------------------------- Crus Owner's Name ------ ---•------ Phone , �`- ` 1l Address ----------- "✓_ Cit / 4 Y ----------------- Installation Name ._.____ -_r - ---License #4-12V-11_ Phone Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court 1❑ 1 Motel ❑Other ------------- -------------------- -^ Number of living units:___________ Number of bedrooms --------Garbage Grinder ------------ Lot Size ___-_______ Water Supply: Public System and name ---------------------" F ----------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat' Sandy Loam [j Clay Loam: Hardpan ❑ Adobe II 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,) vv. PACKAGE TREATMENT j ] SEPTIC TANK [ ] Size---- -_,t1_-__ �x --------------- Liquid Depth -.59 ..--__.. Capacity '" __ ype Material --- No. Compartments /- ------•-- Distance to nearest: Well _,-5- 0___._______:.________Foundation --/ ------------ Prop. Line _.r�_G�e LEACHING LINE { } No. of Lines ----_GTc____________ Length of each lin _____ L�_-___________ Total Length .___�s _-.._______ V Box ----/----- Type Filter Material _��__ _-___ ;_.Depth Filter Material ---------------------_--------- __ Distance to nearest: Well �r�I�____ _:_____ Foundation __ .__l�___�________ Property Line ----- I .4 i SEEPAGE PIT ) Depth ---------- Diameter 26_ ___ Number _______________//___________ Rock Filled Yes No Water Table Depth --------- --------------------------Rock Size Distance to nearest:-Well ...L" _-----_----------------Foundation __l ---------- Prop. Line-------- ...... ; REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------_----------_) Septic Tank (Specify Requirements) --------------------- ----------------- Disposal Field (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------- 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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- i sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is.issued, I shalt not employ any person.ein such manner as to become subject to Workman's Compensation laws of California." Signed ---------- - ----- --------- ------ ------------ Owner 8Y - -- Title ----------------- (If other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- --- ------ .. - ------------------- DATE ---- BUILDING PERMIT ISSUED -- ---------� -----DATE ---------------------------:---------------- ADDITIONAL COMMENTS ___ ----- -- ----------------=------ ---- ----------------------------------------------------- --- ------------------------------------------------------------------------------------------ ----------------------------- ----------------------------------------- ---------- --- ----- - ---- --- --------------- --=----- - ---------- ------- ------- � ------- Y Final Inspection by: Date ----- - "- --- ----!SA JOAQUI LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M