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FO- --R OFFICE- - -USE- - :-- ------ Permit No. i_/1.2-APPLICATION FOR SANITATION PERMIT G_=2dJ'¢ - - --- ---- �- - -- (Complete in Triplicate) 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 made in compliance with County Ordinnce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT NCS ------- - --- -------------- - CENSUS TRACT .. �; Owner's Namer p ---- --- _ -----------Phone -------- ------------------------ --------a-O ------ --------- -------------il City ------------------------------------------------ Address - o E Contractor's Name ________ _License # _r�� y Phone __'__________________________ --- --- ---------- - - -------------- ------- Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court TI `Motel ❑Other ..--------- . -- Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ...... __ - ___________ 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,) \n PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size-------------------•------------ ----------:---- Liquid Depth -------------------------- I Capacity Type".°"°... `�"'Nlafieria) -- ----------- ,. -_r__�.No. Compartments ------------------=-=- e Distance. to. nearest: Well -----'----- --� '" Foundation ----------------------.Prop, Line --_------------------ Distance --------- - LEACHING LINE. [ ) No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------_-------------- --- 6_%'D' Box ------------ Type Filter Material----------------------Depth Filter Material -------------------------------------- Distance to nearest: Well ------------------------Foundation ---------------- ------ :Property Line ------------ ------------ SEEPAGE PIT [ } Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance#to nearest: Well ----------------------------------------Foundation ----------_----.---- Prop. Line ---------------.--.--- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------.---------------------------) SepticTank (Specify Requirements) ---- ------------- ------ ------------------------------------------------------------------ -------•----- _---------------------_--- 4 Disposal Field (Specify Requirements) ------------------ - ------------- ------------------------------------------------------------------------------------- 'y -�{ a -•-------------_--------- -----------60------- -------�---------/---- ---- --- _-A---------------------- -------------------------------------------------------- - - ------- -- ---- - -- ------- (Draw existing and required additi n on reverse side) I hereby certify that I have prepared this application and that the work will be done-in accordance with San Joaquin _ I County Ordinances, State Laws, and Mules 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 s b)ect to Workman's Compensation laws of California." Signed = Owner nCZ /�- CJ= title -------------�` ---------------------- BY --.------------- - (If other than owner) Jr FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ----y----------------------------------------------- DATEt7_ -y--------- --•------------------ BUILDINGPERMIT ISSUED ----- ----------------------------------------------A----------------------------------------------------DATE -----------------------------------------•- ADDITIONALCOMMENTS ----------------- -- -------- ------------------- ---------------------------------------------------------------------------------------------------------- -----------=-------------------------------------------------------------------------------- ----------------------------------------------•--------------------•-------------------------------- ---------------=-------------------------------------------------------------------------- -------------------------------------------------------------------_-----(------------------------------------------ - -----T-- -- ---- -----------------------------------------ed� e� --- Final Inspection by. ----- -------- - Dat --- -�-`-. -�� ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M.