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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: (Complete in Triplicate) ---------=----------------------------------------------- Date Issued ------------ ------------ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to constru t and install the work herein described. This application is made in compliance with County Ordinance No. 549nd zi -'Rules and Regulations: ------ ----� JOB ADDRESS/LOC N . �-- ENSUS TRACT -------------- ------- JOB Name -- ` _ n -- --- _ Address ------ . . , Contractor's Name t-.License # 1 �j- Phone w , // Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑, f - Motel ❑Other,------- Number of living units:- 1.----- Number of bedrooms _.____Garbo a Grinder --------- Lot Size -. -------- ----•- Water Supply: Public System and name - •--------- ------------- --------------- --------------------------. ------------ Private Character of soil to a depth of 3 feet: Sand'❑ ilt❑ Clay E] Peat El Sandy Loam ❑ Clay Loam El F Hardpan Adobe ❑ Fill Material ------------ IfYP,estype - -_-'t-------------------- Y , (P1'0t plan, showing size:of_,-.Ibt, 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------------------- --- Liquid Depth -------------------------• Capacity -------------------- Type -----r-------------- Material-- ;------------------ No. Compartments --�------------------------- `- ------------ a n -----------------------Prop. Line -------------=• ------ Distance to neares#:- Well `�`- � Foundatio- Total Length LEACHING LINE [ I No. of Lines ------------------------ Length of each line--._:-.---------. -----=---------------------- D' Box _--- ...... Type Filter Material -;--- 'repth Filter Material --------------------=----------------- __i Foundation Distance to nearet: Well -------------- n ------------------------ Property Line. =-----------•--•---=---- a SEEPAGE PIT Depth --- Diameter ---------------- Number-------------------------- Rock Filled Yes '❑ No C3 - -------------- `-`-----Rork Size -------------------------------- Distance ----------------------- --•-- Water Table Depth ____________________ __ - Distance to nearest: Well ------------------------------------\-Foundation ---------------.---- Prop. Line ..-------------•------ REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------•-------------:,Date ----- ------------------- =--1 Septic Tank (Specify Requirements} -------------------- --------- ` '------x�--- --��_-------- .�/ Dis osal Field (p cify Requirements)-..i---'% — -- f , f rx -�� ----- ----- - el /lip L --------- ----- ------- -- -------- - ----------- -------------------- --- -- -_---_-------- I---'---------- "- -- ---------------------- ---- --------------------------------- ' (Draw existing and required additiori-ori reverse-side) 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. Horne owner or licen- �sed agents signature certifies the following: r "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 sub' Workman's Comp e n laws of California." E i Signed ------- -------------- ---- --- ------- ----- ---------------. Owner �. ,..q ii -� 'o T -.. .- _ . ti.4 (If other than owner} R• FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------- ----------------- DATE -Cp-`--1 __-- -------- BUILDING PERMIT ISSUED ----------------------- ----------------- -------DATE ------------------------------ ------ ADDITIONALCOMMENTS ------------------------------------- -------------------------------- --------------------------- --------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- - ------------------------------ --------------------------------- t Final Inspection by: - Dae - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M. �t