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FfJ12 QFFICE USE: APPLICATION FOR SANITATION PERMIT Z_,.. 09 R (Complete in Triplicate) ;> Permit No: - -�______ ` ------------ --------------------------------- ------------%----------- -----------________________.__._.__-_.________________±.______.___ 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION -- - - - ---- -- -'-- --- -------------------- - -- ------------CENSUS TRACT' --------------I----------- Owner's Name !-Vii_- - p� �l! -- -r- Phone 77 p Address ------------ Q--- - -- ----- --------------------------------------•--- City ------------------- Contractor's Name _- ----________--------License # ---- Phone �fD ___ Installation will serve: Residence %Apartment House❑ Commercial :❑Trailer Court i❑ Motel E] Other ----------------------------------- -------- Number of living units:-----[_r_____ Number of bedrooms ----3----Garbage Grinder ----_- - ___ of Size _( , �� -s------. --- . Water Supply: Public System and name ---------------------------------•--_--------------------------------1•--- --------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe)5� 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.) W -NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ize *J' _ X_9__X_____________.___,.__ Liquid Depth __ ._7______________ (4 CapaeitylZ00 --------- Type a ------ Material No. Compartments ___y_�__ �------ ._ ,V Distance to nearest: Well _________________________________Foundation ....lQ__p------- Prop. Line _---.5--__---_______ LEACHING LINE [ ] No. of Lines --------- Length of each line------- V_____________ Total Length ------✓f��G l® _ .�--.____._..._.._._ 'D' Box Type Filter Material -� ------Depth Filter Material ___ __ _ l�_«___________ . , Distance to nearest: Well _______________________ Foundation _____-40._______-__ Property Line. ___�______-_--_-_- SEEPAGE PIT [ J Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------ -------------------------------- --------Rock Size -------------------------------- Distance to nearest: Well ------------------------------- -------Foundation -------------------- Prop. Line --------------------_. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----______________________________) Septic Tank (Specify Requirements) ---------------- ------------------------------------- --------- ------ --- _----------------------------- Disposal Field ISpecify Requirements) ------------ -------------------- -- --------------------_.--------- -------------------•--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----- - Owner CLA� ----- Title ------------- (If oth han owner[ FOR D PARTMENT USE ONLY APPLICATION ACCEPTED BY _ ____ _-�' 'r _ ____. DATE --- -�_-� _:__'_ .__-_.____ BUILDING PERMIT ISSUED ---------------------------------- -----------------------------------_-DATE ------------------------------------------- - ------------------------------------------------ ADDITIONALCOMMENTS -------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ------------------ ------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------- - --- - - ------- - ------ - ---- -------------- --- --------- -- --- Final Inspection by: - ------- ---- -- ---------- - --- -----------------------------Date -_��, l - N J QUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M