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FOR OFFICE USE: APPLICATIOWFOR .SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Triplicate) This Permit Expires 1 Year From Onto _/ _ 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: –� ---------CENSUS TRACT --------------•----------- JOB ADDRESS/LOCATION ,�--��--- -- ----�-- --- --- - ''r' ------ --- - --- Owner s Nome - - Phone Address y- -, --- lv_4"�. -- -- - ----- --- --- -- City -- G -------------------------------------------•-----. Contractor's Name --- - --- -� - --Z - -- -.License #fr _ Phone Installation will serve: Residence ❑Apartment House❑ Commercial :❑ ;E]Trailer Court i Motel ❑ �� Other __ _--�`-�wnx, I Number of living units------/----- Number of bedrooms ___��_-Garbage Grinder ------------ Lot Size ------Q-------------- Water Supply: Public System and name --------------- --------------------------- -------------------------------------------------------•---------Private Character of soil to a depth of 3 feet: . Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom �E] Clay Loam ;❑ Hardpan �/Adobe'❑ Fill Material ------------ If yes, type ---------------------------- {PI'ot 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 [ ] SEPTIC TANK'[+ Size_V _'/lp-110r�----------------- Liquid Depth _l'--i__•___-____._..__ {� a �[ Capacity/. A __ _ Type - ---- Ma#eriaE__td4!?ru---'- No. Compartments __ _cam________________ t Distance to nearest: Well -----------jp-------------------Foundation ----1!95� ......... Prop. Line ------g------------- LEACHING LINE [✓� No. of Lines --------,2.----------- Length of each line---------SQ_'___..----- Total Length _/aa__---------------- 'D' ____________'D' Box -- ------ Type Filter Material ---- ��-----------Depth Filter Material Aef Distance to nearest: Well --------37-,o------------ ------/d_________ Foundation ------ Property Line -- `--- ---- -------- SEEPAGE PIT [Y� Depth ------ Diameter ---93_A3_..-_ Number ----____.2--------------- Rock Filled Yes No Water Table Depth _____________ --------------------------fRock Size Distance to nearest. Well _______________ __-----------Foundation ------- Prop. Line ------------ REPAIR/ADDITION REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} Septic Tank [Specify Requirements] --- --------------- - ----------------------------------- ---------------------------------------------- Disposal Field (Specify Requirements) ------------- --------------------------------------------------------------------- --------------- ----------------------- ---- ------------ ---------------------------------------- ------------------------------ ---------------------------------------------------------- (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 i BY ------ Title ---- --- --------- -- ----------- -- -- ---- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- . _ - --------------------------------------------------------------- DATE --------------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------- =--------------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------- -------------------------------------------------------------------- ------------------------------------------------------------- ----------------------------------- -------------------------------------------------------------------------------------------------------------------------`------------------ --- -------- r 1 ---- ------_--------------------__---------------_---------------------- -- _- _ :_______ Final Inspection by: ---------------------.Date _/y~ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H- 9 1-'68 Rev. 5M.