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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: -- 7 - 3 S� --------------------------------------------------------- (Complete in Triplicate) - Date Issued This Permit Expires 1 Year From 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- ------------f CENSUS TRACT .----- ----- JOB ADDRESS/LOCATIONa laePhone ------------------------------------ I 'Owner's Name �---- '_ _ ^/-------------------------- ---------------------------------------------- F ---------------- ---------- r Address _ _ City 1-'fo ------------•------ -------------•-----------•-------•--- , 1Q----• Contractor's Name ------/, ---.License # ------------------------ Phone ------------------------------ Installation will serve: Residence ® Apartment House❑ Commercial:❑Trailer Court ❑ Mote! ❑Other ------------------------------------------- Number of living units:----./----- Number of bedrooms __%3------Garba_ge Grinder ------------ Lot Size ------ -------- Water Supply: Public System and name ----------------------- --------------------------- -------------------_-Private J Character of soil to a depth of 3 feet.. Sand'❑ Silt❑ 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,) SEPTIC TANK Size_�4►�� - ------ Liquid Depth - C . PACKAGE TREATMENT { ] Rl '-------- Material_4-4wry----------- No. Compartments ------ Capacity��-�------- Type -- Distance to nearest: Well __-c d------------------•-_-_---Foundation _l- ____'________ -- Prop. Line _ ._-_,__:. --_--- LEACHING LINE ] Na. of .Lines ---;4. Length of each Vne--/&-'*----------------- Total Length _ �------------------- -------------- 'D' Box ---_ Type Filter Material _�-�_--__--_Depth Filter Material _-_�fK------------------------• - 76' -- - Foundation -J-a- ------ Property Line 'S, Distance to nearest: Well ----- _____________ __ SEEPAGE PIT ,�] Depth _ ........... Diameter --- ------ Number -------- ___-- - ------ Rock Filled Yes. No Water Table Depth -----60-------------------------------------Rock Size -------------------------------- Distance ----="----------------Distance to nearest: Well -----/-OT*------------------- -- ----- ---- Prop. Line -%r+------_-------- + REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------ ------------ --------------) f Septic Tank (Specify Requirements) _--------------------------- --------------•-----•------------- Disposal Field (Specify Requirements) ---------- -- - ------------ --------------------------- ------------- ---------------- - ------------------------------- -------------- ------------- -- ------------ -------------------------------------------------------------------------------------------------------------------------------- . t (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: F "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 -- --I-------- Owner ' ------ ----------- Title ------------ ----- - ------- ------------ ------------ --- BY d other than owner) FOR DEPA1tTMENT USE ONLY APPLICATION ACCEPTED BY __ --- -- ----------------------------------------------------------------------- DATE '-� "Z�-.---- ----- -------- BUILDING PERMIT ISSUED -------- ---------------------------- ------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS - -------------------------------------------------------------------------- ---- ----------------;-------------------------------------------------------------------------- ------------- - : . ------------------------------------ - Final Inspection by: ___ - - Date - - ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M