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FOR OFFICE USE, APPLICATION FOR SANITATION PERMIT Permit No: --------------------------------------------- ---------- (Complete in Triplicate) ----------------- --------- ---------- ---------- This Permit Expires 1 Year From Date Issued----- Date Issued -----------------------------------------:----------- Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No_ 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .-----��-l------�--�-/-��-� --------- ---- ---- CENSUS TRACT -----�'--�•----•--•- i�t _� RI ------ Phone Owner's Name - - Address `c? --./ d Phone, �]� {� License - _L � 3 O _._- Contractor's Name __ -- - _ --------- -- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ------------------------------------------ Number of living units:___-._ __ _ - Number of bedrooms ___R----Garbage Grinder _.--____.._ Lot Size Water Supply: Public System and name -------- -------------------------------- ----------------------------------- Private 17 -..�+ - Loam Character of soil to a depth of 3 feet: _-Sand Silt El Clay ❑ Peat ❑ Sandy Loam ❑ Clay ❑ Hardpan ❑ Adobe ❑ Fill Material __� -- If yes,type ------------------------ (Plot plan, showing size of lot, location of system `gelation to wells, buildings, etc, must be placed on reverse side.} NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) SEPTIC TAMC Size -_-- ---- _-��- � -- -. Liquid Depth - PACKAGE TREATMENT [ ] I �apacity _JQ .--- Type �i �' aterial o. Compartments __ ......... __Foundation --- --- -- ----- Prop. Line ._ ------•----• istance to nearest: Well ____---- �------- -------- f � I [ C -----_- Length of each line___-7-d--------------- Total Lengthp916-------------- ! LEACHING LINE No. of Lines _______ _________ p 'D' Box ._ ----- Type Filter Material ��P-----Depth Filter Material _- /---------------------• Distance to nearest: Well ---.ate Foundation -/_6- ------------- Property Line cid--.----------------- SEEPAGE PIT [10j/ Depth _ _ Diameter ------------ --- Number --------------------------- Rock Filled Yes ❑ No I❑ Water Table Depth __ Rock Size -------------------------------- Distance ____.._--____-_.__--__ _Distance to nearest: Well ____.___ _____---- -------------------Foundation -___.__------------. p• Pro Line -------------- ...... REPAIR/ADDITION(Prev. Sanitation Permit# -------_-------------------------------- ----------- Date ---------------------------------- Septic --------------------------------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 Work an's Compensation laws of California." s Sig ned ------ - ' Owner By --------------- -------- --- --- ------- Title - ---------------------------- - --- ---------------------------- i (If other than owner) FOR DEPARTMENT USE ONLY '] i APPLICATION ACCEPTED BY ----- �---- -`------C------------------------- ----------------------.- DATE _.:C�-- { BUILDING PERMIT ISSUED ____________________ __ ---------------------- ------------------------DATE ---------------------------------------- - ADDITIONAL COMMENTS - --------------------- ---------- -------------------- - --- - - -------------- --- ---- -- -- ------------ -------- - ---- - Final Inspec ' SAN JOAQUIN LOCAL HEALTH DISTRICT r H_ 9 1-'68 Rev. 5M