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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT" --- - -- -------- - - -- (Complete in Triplicate) -L'- Permit Na- ------------�Q� it Date Issued -------_.---.---.-__---------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby mad 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 Ordinance No. 549 and existing Rules and Regulations.. I JOB ADDRESS/LOCATION :_�J_--_ _.�.__ ._ .. --------- _ . JQ - ------- ------CENSUS TRACT ------- --•----------- Owner's Name ---1== /41-----` _!0//-------------- ------------------------------- -------Phone Address ,71� M`---- p [�1/f! -----. City _ _ �1�- = Contractor's Name .- E ~.._F---- C✓[--TG = -------------- -_-----------License �_ Phone Installation will serve: I Residence '7>partment House Commercial:❑Trailer Court 1❑ P' Motel E] Other ---------=------------'------------------ -- Number of living units:.... __.._ Number of bedrooms ________Garbage Grinder _r _'_ Lot Size _ --------------- Water Supply: Public System and name _______________ t _____Private Character of soil to a depthl of 3 feet: Sand' Silt❑ Clay-:L] -Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe E] dill Material --[old - If yes,type -----------------____________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) i NEW INSTALLATION: (Na septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT I ] SEPTIC TANK{ ] ,�'" Size------------------------------------------- ---- Liquid Depth -------------------------- NZN Capacity ------------------ -Type -------------------_ Material------------ ---- ----; No. Compartments ---------------------- , l _ Distance to nearest: Well ------------------------------------Foundation ---.------------------ Prop. line ------------.--------- W LEACHING LINE [ ] N 6. of Lines _____________ Length of each line_.____._._.__.__ Total Length ________-___--_.__.___.____ 'DBox ------------ Type Filter Material ._________ -------- Filter Material ----._____________________________________ I�. Distance to nearest: Well ------------------------- Foundation -------- Property Line ------.___________-.---_ SEEPAGE PIT [ ] Delpth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Dis�tance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ._-------------------- , REPAIR/ADDITION(Prev. Sanitation Permit# -------- -----------------------_------- ___ Date --- ---------------------------- lM Septic Tank (Specify Requirements) ------ I l?- --------- Disposal Field {Spec ifyRequirements} _�ryyl ___ _ = __-- dsr�t----- -a`Yy��' ------------------ --- -------------- ------------------------ --------------------------------------------------------------------- -------------------- ------------------ -------------- --- (Draw existing and required addition on reverse side) 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 Wor an's Compensation la s of California." Signed - ------ - ---------------- -- -- ---------------- --- --- ----------------------- Owner By ----- -- -- - ---------- - Title ------- - ------------------------------- --------------------------------- (If other than`owner} II FOR DEPARTMENT--USE, ONLY APPLICATION ACCEPTED BY .7r7►R 5?------- ----------- -----------------------= ------ DATE .�_ 6- �' ------------------- -- BUILDING PERMIT ISSUED'---- ----- ------------------------------------------------------- ------- `---------------DATE ------------- ----------------•------ -------------- ADDITIONAL COMMENTSa - -- ---------------- -- ---- --- --------------- ------- --- -- --------------------- ----------------------- --------------------------- - --- ----- ------------------------------------ - ------- ----- -------- ----- - -------------------- ---------------------------------------------------------------- ----- Final Ins ection ----------.Date ---------- `- - ------------- P -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'h8 Rev. 5M , /