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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------- .,..$ _ -�---�-- �------- ------ (Complete in Triplicate ----------------------------- -------------------------- Date Issued ------ This Permit Expires 1 Year From Dale issue ermit to construct and l the work herein A described. on is hereby inion is mean Joaquin Local n compliance wi health Cou tyfirict for a Ordinance No. 549 and existing Rulesfialnd Regulations:described. This application s JOB ADDRESS/LOCATION -" ' lw - 71m° P-ENSUS TRACT _ _ - --- - - --- - --------- ------Phone ---- ------------------------------- Owner's -- ----------------•-------•------ Owner's Name __ •--------------------- --- I] • Ci ----------- - .- - ----- --- -------------------------- Address ------------� 7--"�f- / ------)? - - - r -- ----•--- ----.License # - ---------------------- Phone ----------------------------- Contractor's Name --------------------=---------------------------- - --- ------- -- - installation will serve: Residence.K] Apartment House❑ Commercial:❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units.--I----_--- Number of bedrooms -3---_--_Garbage Grinder --------- -- Lot Size "_--__�--------------------- Water Supply: Public System and name -------------------------- ------ -- ---------------------------------•------•-------------- Character of soil to a depth of 3 feet: Sand'[-] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 I --------- (Plot � Adobe ❑ Fill Material ------------ If yes,type�____-- --- - -- � I ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.} } 4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet, d Liquid Depth -------------------------- PACKAGE TREATMENT I I SEPTIC TANK;[ ] Size---------------------- ------ q p Material---------------------- No. Compartments --------••--------- CapacitYl---------------- - Type 1 Distance i to nearest: Weil -------------------- Foundation -------------------- Prop. Line -------------=-- Length of each line---------------------------- Total Length -----------• -------•---- LEACHING LINE [ ] No. of Lines ------------------------ 9 Filter Material ------ ---------------------------•-- ...... 'D' Box ------------ Type Filter Material -----__-_--_-__- .-Depth Distance to nearest: Well --------------------------- -- Foundation ------------------------ Property Line ------------------- Depth Diameter ---------------- Number ------ --------------------- Rock Filled Yes ❑ No SEEPAGE PIT [ � ~--�— --------Rock Size -------------------------------- Distance -------------- ------ Water Table Depth --- -------------------------------•------- - ------- --------Foundation ----------------•--- Prop. Line -----------•-- -----•- � Distance�to nearest: Well "--_"--__"--_____"__ __ - , ) REPAIR/ADDITION(Prev. Sanitation Permit -------------------------------------------- Date - --------- Septic Tank (Specify Requirements) ------------------------------------ --•--------------------------•-- Disposal Field (Specify Requirements) ---•__,"------------------------------------------------- ---------- ------- r"'t - �. 3, F � �. * .�" - ------------------------- --------- ---------- r- - T: (Draw existing an requxfed, dditq�n on teverse side) I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaqufn 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -- ----------- Owner -- - _ _ _ --------- -------- Title ---- --------- --- ---- -- �------- -------- - ' �' -------- By (if other than owner) FOR DEPARTMENT USE ONLY �� DATE _ - 7 6�-------------------- APPLICATION ACCEPTED BY __ � � - - ----- - -------------- -- - BUILDING PERMIT ISSUED --- -------- ----------------- -------- -------- --------- -----•-- ------- ADDITIONAL COMMENTS -------I---------------------- ---------------------------------------------------------------------------------- ------------------------ ---------- ---------------------- --------- ------------- --------- --------- --------- ------ ------------- -- ----- ---------------------------------------------------------------- -�51 _4 Date _ ___ -- -------------------- Final inspection by: - -- -- - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M