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FoP.OFFICE USE: - ---- ---- ----- APPLICATION FOR SANITATION PERMIT (Complete in�Triplicate) Permit No. ---------------------------------- 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 Rul s and Regulations: T4 s �.i�4CA� ' � 7q �,� : f. - /s/-el JOB ADDRESS/LOCATION . -f - � ' `'' �' "� �� = CENSUS TRACT Xe- 9 Owner's Name ---- X '� 1 --- _ Phone Address - �� ' 7 =� IT ` '=�� - City �' G �� - �------------------------------------------- r - Contractor's Name aT_ a---------------------------_License # 2/-r:_._f___ Phone Installation will serve: Residence artment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- f/ Number of lj,5Ing units:________ Number of bedr s _ _ ,__Garbage Grinder t Lot Size -- _1,� �------------ ___ Water Supply: Public System and name --------- _ -- ---.-.--L `'` � �/---------------------------------------------Private E]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 C SEPTI TANK'[ SS�e----�/`. ___ ____-------________ Liquid Depth Capacity ��}--____ Type �:" Material----1)��r -6-No. Compartments Distance to nearest: Well _______"Y-----------'_______-------Foundation Z?-------------- Prop. Line __ .......... (1 LEACHING LINE {, No. of Lines g line.__ - /'- .� Length ;441 -ach, ��_ _--______ Total Len�th __ ____�.............. ' D' Box CI�P--- Type Filter Material -_____Depth Filter Material f__________________________ Distance to nearest: Well -- -------.-------,Foundation --/0-/-__--_._ Property Line __ t SEEPAGE PIT Depth ... -C__ __ Diameter - ______ Number _______ ___ ____________ Rock Filled Yes No i❑ H , , Water Table Depth ------I -----------------------------Rock Size J <- 2 -Distance to nearest: Well ------- P__________________________Foundation __ ___!_.__ Prop. Line --—--------___-__ REPAIR./ADDITION(Prev. Sanitation Permit s# -------------------------------------------- Date ----------------------------------I Septic Tank {Specify Requirements) --------------------------------------------------------------------------------------------------------------- ------ ` Disposal Field {Specify Requirements) ----------------------------•----------------n-------------------------------I--------I--------------------------------------------- ---------------------------------- ------------------ ---------------------- -------------------------------------------------------- ----- - ----- ------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 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 By -------- ------ '" Title .- (If other an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE BUILDING PERMIT ISSUED -------- ---------=------------------- -------DATE ----------------------------------- - ADDITIONALCOMMENTS ---------------- ------------------------------------------------------------------------------------------------------------------ --------•-•---------------- -------------- ----- ----------- -- ---------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ----- --- - --- ---- - - Final Inspection by: Date ----------�--------=------- -- - - - - -- - - - --- - - - - - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M