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FOR OFFICE USE: 3 --- ---- - ---- - -- - APPLICATION FOR SANITATION PERMIT -- - - - ---------- -- -•- Permit No: _--- ----�-�p-�-. (Complete in Triplicate) ---------------------------------------------------------- This Permit Expires t 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 Ordinance No. 549 and existing Rules and Regulations: r7fJOB ADDRESS/LOCATION -- 1 -- -'--f -- ---- _�'-----------/ � j21IV�STRACT -------------------------- Owner's Name -------- -- -•---------------------------------=-------- -------Phone ------ Address � r I-#�r{i City /�1211.17v'-` �y p�-- Contractor's Name ------- _-----'-------------------License Phone Installation will serve: Residence Apartment Nouse❑ Commercial :❑Trailer Court C] Motel ❑Other -------------------------------------------- Number of living units_____________ Number of bedrooms _______Garbage Grinder ------------ Lot Size ---ACA- ___________-_.________ Water Supply: Public System and name ------------------------------------------- ------------------ ------------------------------------------------Private [, Character of soil to a depth of 3 feet: Sand'0 Silt E] 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,) PACKAGE TREATMENT [ } SEPTIC TANK [ ] Size --__��1'__L`�.-��------------------ Liquid Depth ___7--�-______.._. Capacity o'10.P----- Type P/_Z�A�Material_�6410Z �No. Compartments -- 7------------_- Distance ._ ---_- __. Distance to nearest: Well -----_---7�__ _____________Foundation--- - - -------- Prop. Line ---6-1- ------- LEACHING LINE [ ] No. of Lines __- ______________ Length each line_____ 5�6------------- Total Length 2-.14/0-11....... Gl. 'D' Box ___________ Type Filter Material ___________________Depth Filter Material ---�_ '1�______________ -----_-----_-. Distance to nearest: Well ___._5,� __________ Foundation ----1-d--/------- Property line __C�---�____-....... 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 ----------------------.-----------) 4 Septic Tank (Specify Requirements) ----- ------ ------ --------------------------------------------------------------:------------- •.�---------------------------- Disposal Field (Specify Requirements) -------------------------------•----------------------------------------------------------------------------------------- ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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: l "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 F --------------------- --- ----- _ Own er " . ---------BY nTitle (If other er FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---I-------- /------ DATE f ---- --------------------------------- BUILDINGPERMIT ISSUED ------------------------------------ ---- ---------------------------------------------------------DATE -------------•---------- ADDITIONAL COMMENTS --------------------- ------------------------------------------------------------------------------------- ------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••--- ---------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- -------------------------------- t { -------- ------------------ ---- ----- ------ -- ---- Final Inspection by: --- - d-- � --�r --------- ---- -- -- ---------Date ----------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.