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pck FOR OFFICE USE: (2 e-C:E Wt APPLICATION FOR SANITATION PERMIT q �-f u (Complete in Triplicate) Permit o_ - ------- --------- ----------------------------------- / ___-_.__ ----------------------------------------------I 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 de in compliance ith County rdi ace No. 5 19 ap�lt.existi le and Regulations: -- --- -------------------- TJOB ADDRESS/LOCATI �-. SURAC ____._._ Owner's NaMe ------- -- --- - ----- - ••. ------------------ ---------------------------------Phone ------------------------------------ AddressQC �UR -V`C. ._� City - ---------------------------------------------- .. ---------------- - - -- Contractor's Name � — / 7 License # _�?.. Phone� > �s l Installation will serve: Residence .Apartment Hse,❑ Commercial ❑Trailer Court ;❑ Motel ❑Other------------------------------------------- Number of living units:---- Number of bedrooms ---I-------Garbage Gri er ------------ Lot Size ._�_ --------------- Water -p..--_.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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-----------------------------------.------------ Liquid Depth __________-_-.-._.-. -_. Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------------ ------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................1. LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_____ __.__..__ _ _____ Total Length ---------______________ ___ 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------------- ..................... x"09 Distance to nearest:.W.ell Foundation -----------____ _-_____ Property-Line ___....__._—._....... SEEPAGE PIT [ ] Depth ---- ___r_. Diameter ---------------- Number ------ --------------------- Rock Filled Yes ❑ No ,0 Water Table Depth -------------------------------- •-------- --Rock Size -------------------------------- Distance to nearest: Well ___________________________________j Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------.LDate -.____--____________---_------_-__) Septic Tank (Specify Requirements) ---------------------------- --------------------------I--------------------- ------ ------•---------- -----------•t -------- Disposal Field (Specify Requirements) = x - -*�-�__�. } -c.✓ ��-�-e � ,© .� -----------1------- ----- --------------------------------------------------- -------------------------------------------------------------------- (Draw existing and req it d addition on a erse side) I hereby certify that 1 have prepared this application--cmd-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 s' nature certifies the following: "I certify t t n the performa of the work for which this permit is issued, I shall not employ any person in such manner as to beco ubject to WoM's CoLpensation I sof California." Signed - ----- -e,..v_s�s ..... -.._. BY ---------- ------------------------ --- --------/_.- Title --—----------------------------------------- (if -r----------------------------------------- (If other than owner) FOR DEPARTMENT ,VSE,9NLY APPLICATION ACCEPTED BY --------------------------------------- -----. DATE --- ---------------- BUILDING PERMIT ISSUED -- - -- ---------------------DATE ---------------------------------------- ------ ------ ------------- -- - -- ADDITIONAL COMMENTS ___________________._______.___ --- - ----------------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------- ------------- - ------------------------------------------------------------------------------------------- ------ i ----- -- - - -- - ----- ---------- - ------ Final Inspection b -_._-__-___.Date ____ ___ _ _--____ P y: -------------------------------------------------------------- /_C) SAN JOAQUIN LO L HEAL DICT E. H. 9 1-'68 Rev. 5M