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TOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------ ---------------------- [Complete in Triplicate] Permit No. _-_7 --------- ----------I------ --------------------------------------- This Permit Expires 1 Year From Date Issued Rate Issued - -_ a_-73 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. 5,499 and existing Rules and Regulations: JOB ADDRESS/LOCXT N . 7I ---- ---- ----- 1- CENSUS TRACT _S '� Owner's Name // --- ---- - --- -- ---------- ----------- ---- Phone Address �9-l=-, ------ Cif -------------- ---- cit. ------------------------------------ Contractor's - -------------------------------- Contractor's Name , _ ` ----------=--------License # _ � .. ------- Phone --------------------- •------- Installation will serve: Residence ❑ Apartment House-[] Commercial ❑Trailer Court 1❑ Motel ❑Other ----- -- -- ,-------- - Number of living units:----.- ..__ Number of bedrooms --_Garbage Grinder ----_----..- Lot Size ------------------------- ---------------- Water Supply: Public System and name ---------------------------------•---------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe ❑ Fill 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: JNo septic tank or seepage pit permitted ifl public sewer is available within 200 feet,) 4�(J �/ PACKAGE TREATMENT [ ) SEPTIC TANK Size_____/,I------X___�------ ____-- Liquid Depth _--_44--------------____J Capacity - -� - Type /1 - __- MaterialNo. Compartments ____P-- /--_-__ - Distance to nearest: Well ---------,.?u .-__--Foundation --i-A------------ Prop. Line ----�_-_-,_..... N LEACHING LINE [A No. of Lines -----2------------- Length of each line.----._�v___--... Total Length �-(�...............rn D' Box --- -------- Type Filter Material -___..e___ ___Depth Filter Material ------- ---------------------------- Distance to nearest; Well _--- ------ Foundation ------- _ -�----------- Property Line ------------------•--•-- SEEPAGE PIT Depth �- 1--- Diameter �_ r` Number -.-_---___ '�1 p --� -- -_----- �--/--�-- .-- Rock Filled Yes (A-"No ❑�' Water. Table Depth -j ---..Rock Size ---1 �--_, 3- >>r� .. Distance to nearest: Wel! -------.1v�---------------------Foundation -.-1__(.l____---.-- Prop. Line -__�......--__.� REPAIR/ADDITION[Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) P SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------- -------------------< --------------------------- Disposal Field (Specify Requirements) ------------------------------••------------------------------------------------------------------------!�------------ ----- - ., i . •--- ------------------------ ---------------------------------------------------------------------------------------------- t (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 k 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 an's Compensation laws of California." Signed -I- -- n n Owner BY - ------------------------ -- - - �/r �, - - - -- Title -----"-.- : !_t''' �----- [If tithe han owner) � - FOR- DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- - ----- BUILDING PERMIT ISSUED ----------- -- ---------- ------------------------------------------------------------ '------DATE ----------------------------------------- ADDITIONAL COMMENTS l ------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- - ----- --------------------------------------- - Final Inspection by_ ________ __ _ _ Date -. - --&- ------------- -------------- --------------------- - ----- - • -----_---_-------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M bow