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FOR OFFICE USE: 'PLICATION FOR SAN ATION PER; u L I U C-U vy (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: ---CENSUS TRACT -------------------------- JOB ADDRESS/LOCATI N Owner's Name -- / - ---- ---------------Phone ------------------------------------ Address - -------------- ------ - �---- �--�--,E�_ _�__ ._--------�- ------------- ----------- City ------- - - - -.-- Contractor's Name _.------ -----------License # Phone _-____-_--___________________ Installation will serve: Residence apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other .... ____________________ Number of living units:___ _____ Number of bedrooms .___1'._ _Garbage Grinder ------ ----- Lot Size ------------ --______________ Water Supply: Public System and name ----------------------•---------•--------- ------------------------------------- -------------------- --------Private Character of soil to a depth of 3 feet: Sand' Silt❑ Clay E) Peat E] 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,) / r ! PACKAGE TREATMENT [ ] SEPTIC TANK [0'� Size _ ! -_i r_ ___�-. ____ Liquid Depth - Capacity -1"L6 ----- Type--------_ Material_- No. Compartments ________________ Distance to nearest: Well ___-___Ste.__!___________________Foundation _-.-_1-_[z__�___-._ Prop. Line _--_ '_-__--_______ LEACHING LINE [� No. of Lines . . _.___-__ Length of each line- --_-60.--r--....-_-_- Total Length _-« ................. 'D' Box _ ____.-_- Type Filter Material ___-_41!x_!--___Depth Filter Material ----j1� �_______________ Distance to nearest: Well -------Sl-'__"-__-___ Foundation ........Lcr? �' __._-_ Property Line -_____-__ SEEPAGE PIT [ Depth --- `s_ _-____ Diameter --- 3 Number / ____ Rock Filled Yes 0�No Water Table Depth ------------------------- ----____--._•._.._Rock Size --- -------------------- 41 Distance -_-- )_•-_-•_-- Distance to nearest: Well ------------JQQ---------------------Foundation ...... _o__`------ Prop. Line -�._________._______ REPAIR/ADDITION(Prev. Sanitation Permit# -----____---------_------------------------- Date ___-___-___--____________________-1 Septic Tank (Specify Requirements) ............ ---------------------------- ---------- --------------------------•--------------------- -- --------------------------- Disposal Field (Specify 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---- Owner ----------------------------------------------------- By ----------- -- 1 = ``t�----------------------------- ------- Title --L er+vL'' t -L --------- --. ----------- -------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------- ---------------- DATE --------------- BUILDING PERMIT ISSUED --------------------- - --- -------------------------------._DATE -------- ------------------ ---------- ADDITIONALCOMMENTS ----- -------- --------- ------------------------------------------------------------- --------------------____--------------_---- ------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- --------------------------------------------- ------------------------------------------------------------------ --------------------------------------------------------- ••-------- -- ---•- _________________________________________________________________________ __________ _ __________ ial Inspection by: - ----- -----------Date Y.,- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 9 1-'68 Rev. 5M