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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ��3 f 7 -� - p p "• ' permit No. --- 1 (Complete ir: Tri licate) 4`:% r _______.______..___________________________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made tb the San Joaquin Local Health District for a permit toicon struct and install the work herein described. This application"is made in compliance with Countyrdinance No. 549 and existing Rules and Regulations: t i JOB ADDRESS/LOCATIO "! . - ----- - ----------------------- ----------CENSUS TRACT -f------------------------- Owner's Name ----------- ---- ----- G ------------------ , fi -_____:Phone Y__ Address ---------------------------------- - ------------ Cit 1-------------------------- Contractor's ------------ --------Contractor's Name ----------------- ------------------------ --------License # ._ -----.----------!-_�Phone Installation will serve: Residence ❑ Apartment House-E] Commercial:❑Trailer Court ;0 Motel ❑Other -------------------------------------------- . czeNumber of living units:---1___._ Number of bedrooms ___ ___`_`��rbage Grinder _.___- -__ Lot Size { -------- ----------- I i Water Supply: Public System; nd name ---------------------------------•-- ---- ' - _ = Private Character of soil to a depth of 3 feet. Sand'o Silt❑ Clay ❑ �` Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ____________ If yes, type ---------------------------- t (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed ori 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 I YP --------------------- - - - - - Foundation Prop. Line T e --- - -- ateria __________________ I / Distance to nearest. Well n tom artp Line LEACHING LINE [ ] No. of Lines ----- --------------- Length of each line__________ Total Length ---I------------------------ 'D' --_-._-__-- -_ ---_'D' Box .----------- Type Filter Ahaterial --------------------Depth Filter'Material -------------------------•--......---..----- f Distance to nearest: Well ________________________ Foundation ----!,_ i_ a'`� Property Line ;__,___..___..__.__-_____ SEEPAGE PIT [ ] Depth _--_I Diameter ----------------- Number ------------l_________1------ Rock Filled Yes ❑ No I❑ f: Water Table Depthl—----------------------------!-�--.•--'----Rock Size -------- -- �� Distance to nearest: Well ----------'---------- -----------------Foundation�;G ___ _�-a�-± tProp. Line ...._-_ .............. . �. - -� , REPAlR/ADDIT N Prev. Sanitation Permit# ------------------ ---------- ------------- Date ---------____-- ---------____--�-) 1 t Septic Tank [Specify Requirements) --------- -- ""�� _----- —r._ 0 --- -- - .,. ----- - ----•- :_;_ ----- Disposal Field (Specify Requirements) -- .- 1 _-------- --------- ----- - --- ---------- ----------------------- ----- -- ------------------------------------------------=------------------------------------------------------ ` ° --------------------------------- i (Draw existing and required'addition on reverse side) I I herebycertify that I have prepared this application and that-the work will be done in accordaricel 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: ice! ! i "1 certify that in We.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 ---------- -------- r ` ---------------------- Owner -------------------- ------------------- Title -------------- IlII --.- - han o�ner)BY -- I----- --- OR DEPARTMENT USE ONLY APPLICATION ACCE?TED BYl....A-1-------6IM&7---------I------- 1 -------- -------------- DATE _-�_��`� ------------- BUILDING PERMIT ISSUED ---+-------------------- -! --r.. �-- —_DATE-- i-----.------------- - ------------------ --------------------------------------------------- -- ----------- ADDITIONALgCc0(1MENTS ----T------------- - ----------------------------------------------------------=--------------------------- ----- ' ------------------------------ F f i.�,i. i ------ ------- ----------J--------------------- --------------------------- s P 4;d Final Inspection by; -- ---- ------------- ------------------------------------------ - Date '" --------------- -------- # SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'b8 Rev. 5M