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FOR OFFICE USE: APPLICATION FOR-,SANITATION PERMIT .- ,�.1 Permit No. ------------------------------------------------ ---- {Complete in Triplicate] -- -0 Date Issued This PermitExpires'1,Year From Date Issued ------------- - ------------- Application is hereby made t the San Joaquin Local Health District for a permit to construct and install the work herein 3 described. This application' made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ; JOB ADDRESS/LOCATION __.__ ------------- 0 "�------- "------- CENSUS TRACT Owner's'Name------ -� _ �_ t �_ - ----- • hone P:� ®�� Pho _ Address -.------- _ c --- 3 _ ( - -__ Contractor's Name ------------ --- ----- Phone _ ___--__- �- - ��.r.y, -------- W ----- --.License # - - .----- -- T Installation will serve: ResidenceApartment House^❑ Commercial ❑Trailet Court ;❑ t , Motel F1 Other -------------------------------------------- _. ! Number of li � ----'-2'--Garbage C d / wmg units:____._._ � .._ Number of bedrooms _ Grinder ------------ Lot Size .__ ___________.-_ -0A----------- r Water Supply: Public Sysfem-and name--------------- _ ------- -------------------------•--------• --------------------Private F]to Character of soil to a depth of 3 feet: Sand' Silt Clay ❑ Peat❑_�N5and -`a- Clay Loam ❑ p ❑ ❑ Hardpan ❑ Adobe Fill Material ----------__ If yes,,type ---------------------------- [Plotplan, showing size of lot, location of system in relation to wells, buildings, et_c. must be placed on reverse side.) p NEW INSTALLATION: (No septic tank or seepage pit .permitted if-public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size--------------- v1 -- ---------------------- Liquid Depth -------_-----•------,----- ICapacity #-------- -------- Type -------------------- Material--------------------- No. Compartments ------------ Distance to,nearest: Well- -------------------- T-:--=------Foundation----------------------- Prop. Line ---------------------- 3 LEACHING LINE [ ] No. of Lines ----------------------- Length of each line-------------__f_____.----- Total Length ___________________________ i 'D' Box ----------- Type Filter Material"------ -----Depth Filter Material ----------- -------------------------------- Distance tc nearest: Well ________________________ Foundation _._____________-------- Property Line ____-________-_---- � ..�.......�..,.._..-.-_ �_. �. ,,_._-, . SEEPAGE PIT' [ ] Depth ----------- -------- Diameter -------- ------- Number ---------------------------- Rock Filled Yes ❑ No C3 - r t._T'Rock-Size---=-==----------------------- Water Table Depth ------------------------------- - t Distance to nearest: Well -----------------------------------------Foundation ---••_`__-------- Prop. Line ---------------------- I 1 k REPAIR/ADDITION(Prev. Sanitation Permit#�____ _____________________ - --- -- t � !' r Septic Tank {Specify Requirements} --------------------------- --------- ---------- --�------ --------------------•--------------------------------------- -------- - - Disposal Field (specify Requirements] _-- - ------ = - �� (Draw existing a re aired addition on reverse si e) 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 Workman's Compensation laws of California." Signed --- ----------------- ------------------ ---- --- Owner a . rTitle ........... r By , (If other than er) z FOR DEPARTMENT`L15E ONLY ` APPLICATION ACCEPTED BY - DATE - ------ _ -- ----- --------------------------------- - BUILDING PERMIT ISSUED -------------------------------------------------- ----- --------------DATE ------------------------------------------- -- ------------------- --- ADDITIONAL COMMENTS ----------------------------------- -----------------------=--------------------------- ----------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- ---------------------- " ---------- -------------------------- T s ---------- --------- - a ------------------------ ------------------------------- Final Inspection by: __._ --------------------------------------Date I SAN JO QUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'68 Rev. 5M.