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FOR OFFICE USE'.. 1 r APPLICATION FOR SANITATION PERMIT / /_�rD---------� ---------- _4G' �� ,. {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 per to construct and install the work herein ' described. This application is made in compliance wit County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION ------- fP ----- - - t ' s.• +�"�.----------------CENSUS TRACT -------------- ------- Q �-- -- -- ----- 1_ ----- ----- Phone"6� -�3-3-6---•---- Owner's Name ------ - --- - ---- ----------------=------ Address } ----------- — - XCitY f }} Contractor's Name(__ "License #l'ao-Vl----- Phone Installation will serve: Residence ❑ Apartment H se❑ Commercial :❑Trailer Court ;❑ '� { Motel ❑ Other --- - --- - QC� Number of living units:-----/f----- Number of bedrooms ____ ____Garboiga Grind) er Lot�SizeI -------- Water r ppIY Public S stem and name _---------------------------- --. --'--------------- .Private ' ❑ Character of soil to a depth of 3 feet: 5 n ' ti M I �I p a d ❑ Silt❑ Clay ❑I Peat❑ Sandy Loamy❑, j ay,Loam ❑ Hardpan ❑ Adobe Fill MateribI ___--------'If yes, type ---------_----------________ (Plot plan, showing size of lot, location of system in relation to welissbuildings, etc. must be placed on reverse side.) 4 NEW INSTALLATION: (No septic tank or seepage pit permitted if publIF sewer is available within,200 feet,l �1 PACKAGE TREATMENT [ ] SEPTIC TANK ] ze_______E_ x= _1___________________ Liquid Depth ------- Capacity _ syl.� i. LL,,�. � I i Capacity 4�)•Type RJ-_--- Material_ .__r___ No. Compartments ------:2_----•- ' Distance to nearest: Well ____________________________________Foundation ----16------------ Prop. Line -----�`_--------------- LEACHING LINE [ ] No. of Lines ________I_____________ Length of each line.__-----_--f--Q__@___-- Total Length Q__-___________ 'D' Box .___- Type Filter Material ---( ___Depth Filter Material _---/If -__--____________________ Distance to nearest: Well ------------------ ----- Foundation -------- -_ Property Line ------------------------ I _- ___y_ SEEPAGE PIT Depth ----Z� Diameter _7-' ��___ Number --_-.---� - 3 [ ] p __ -_-_-__ -__ Royc/k Filled Yes � No Water Table Depth ---------------------------------------------- I� " .1 �� x --Rock Size - -�'-------- - �'=-`------ Distance to nearest: Well ________________________________________Foundation ___/p______ __ Prop. Line ----=s________.-__ REPAIR/ADDITION(Prev. Sanitation Permit# ________ ___________________________________ Date ______________-___________________) i k Septic Tank (Specify Requirements) --------------------- ---------------------------------------------------------------------------- •--------------------------- r� Disposal Field (Specify RIequirements] __--_-____-f--------------------------------------------------------------------------------------- ------------ ---------------------!. -------- ------------------------------------------ -- ( (Draw existA 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 uR les and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifiesIthe 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 Workman's Compensation laws of California." � '�- Signed ----------`�- �----------- --------- Owner------------- ---�------- _ Title -- - -- (If other n owner) FOR DEPAIRTMENT USE ONLY --- .&-%A --------- r \ 0 1 ----------. DATE ---10 g APPLICATION ACCEPTED BY __________ _ BUILDING PERMIT ISSUED ----------------------------------------------�---------------------- -- DATE ----- ADDITIONAL COMMENTS -------------------------------------------- --- --Z _ -----------------J--------{-! --------------- ------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ------------ -------------------------------------------------------------------------`----------- ------------------ fl, ----------------------------------------------------------- -- -------------------------------------- 'IsvoDdFinal fns cion by: ------------------ ------------- ---- --- -------. ate ----- - -{- SAN - JOAQUIN LOCAL HEALTH i-1STRIC7 1-'b8 Rev. 5M I f