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:1OR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. nr.- - -- � -•-,,,�•�y {Complete in Triplicate} '_""`. '• Date Issuedia --- �" "" "" This Permit Expires 1 Year From Date Issued ______ ------ # made to the San Joaquin Local Health District for a permit to construct and install the work herein Application is hereby i application inion is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: described. This app ' ---CENSUS TRACT -------------- ------- ` JOB ADDRESS/LOCATION ------IF--- ' 7 - ' Phone - - --- Owner's NameE --------•-------•----- City �4- c/1T /✓ 1 Address 1 ��- 5 �._ G✓/ y--------------- -- " _ -27� ---.License Phone Contractorq Name _ G------`-'�' ------------------------ #/7 `ES Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ k i Motel ❑ Other s - "! _. nder/yGarbage Gri ? Lot Size Number of living units:--------- Number of bedroom - "" ----- i ----Private ❑ - -------------- Water Supply: Public System and name______________________t__ Clay Loam El Character of soil to a depth of 3 feet: Sand'❑ Silfi❑ Clay ❑ Peat❑ Sandy Loam ❑ I Hardpan El Adobe Fill Material __----" -- I Yes,type _ -- - --------- ----------- ` in relation to wells, buildings, etc. must be placed on reverse side.) (Plottplan, showing size of lot, location of, system NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK [ ]` Size_ Liquid Compartments ----------- - to Capacit i- Type -------------------- Material_ ---=-- ------------- No. C p Y ---------- - } � k Distance #o nearest: Well ___--"-__""-- •--•--------- Foundation --- ---------------- Prop. Line -------------=•----•-- LEACHING LINE. [ ] No. sof Lines -------- ------------- Length of each line------------ Length ---------------------------- Total - 'D' Box ---.-------- Type_ Filter Material -------------------- Depth Filter Material ---------------- - j k Foundation --------------`---------- Property Line. ---------- ------ ------ Distance to nearest: We�1 --- _ } I - , T 'r - ' _` Diameter T Number ---- ---------------------- Rock Filled Yes '❑ No SEEPAGE PIT: [ ] Depth - � ��- Water Table Depth ------ ---------------= Rock Size ----'--------------------- i Prop. Line --------_------ -------------------- Date ------•-------• ,--•---Foundation --------------- --- Distanceto nearest: Well ___________________.____________ I Date ------------- ) REPAIR./ADDITION(Prev. Sanitation Permit y ; i Septic Tank )Specify Requirements) ___-------" ---- -- -- - -------- _ _ _________ ______ _ _ _ _ � T Q_ . � Disposal Field (Specify Requirements) -------- ------------------------------ i ---------------------------------- Ol`E--------------------- = ------------------ -------------------------------------------------- - ! -------------------------------------------------- : ---- (Draw existing and required addition on reverse side) I hereby certify that l 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 Distrlct. Home owner or licen- sed agents signature certifies the following: i "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person. in such manner l as to become subject to Workman's Compensation laws of California." Owner Signed ---- --- °.E BY ---= ------ - - ----- e ----- --------- Title -(If o+6i than owner) �- FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED By . . --- i ` -----------'------------------' HATE ------1� --�----•--------------- ._�_- ' ==----- • DATE - BUILDING PERMIT ISSUED ----___-__:----------=-=�==------ -------------- ADDITIONAL COMMENT -------------- -•----------------------------------------- ---------------------- ------------------------------------------= - - ------ - ------------------------------------------------ -------------------- k . ----- ---------------- ----- Date r1 ------- - Final Inspection b ----•---------------- ------- -------- - ---- - --- - SAN JOAQUIN LOCAL HEALTH DISTRICT E.H. 9 1-'6B Rev, 5M.