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FOR OFFICE USE: I - ------ •. r e. 'PLICATION FOR SANITATION PERPr) (Complete in Triplicate) "' Permit No: _ ]. --_ ------ -- -------------------------- ---------------------- # --------------- This Permit Expires i 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 O dinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LO N�-_155Z _ _ --_1---- ------ --- ----- -_ = ----------- ---------------CENSU T Owner's Name -- -- Phone Eor -- ------ ----- _ -OPY----------- Address _ : �r CirY Contractor's Name _ _ _ __. . -------- --- - -- ------ License # _ _ 0,39-� -- Phone -------------------------- Installation will serve:- -Residence A rtment House❑ Commercial ❑Trailer Court i❑ jMotel ❑Other ------------------------------------- Number ------------------------------- ---Number of living units:-___r_.___.Numberof bedrooms _____Garbage Grinder ------------ Lot Size ---------------------- Water Supply: Public System and name ___________________________ Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .Pff Clay Loam .0 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------------------------------------------------ Liquid Depth -------------------------- W Capacity --------- ----------- Type -------------------- Material-.--------------------- No. Compartments ----------- Distance to nearest: Well -------------- ----------------------Foundation ---------------------- Prop. Line ------------------ LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ----------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material Distance to_nearest: Well ____ __________ Foundation -------- ---__,___ ------Prop SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ._ ___--- - ______ Rock Filled Yes ❑ No 0 Water Table Depth --------------------------------------- ----Rock Line ------------------ - Size ---------------- --- -__ ---------- -- Foundation - --- Prop. Li Distance to nearest: Well ____________________ - ----- --------------- _ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------.______._ } G Septic Tank (Specify;Requirements) _________ ____---- _______ ________ _______ ----------------------------- Disp al Fiel (Spe `'fY Requ ements} -------• - - - -------- -- f - -- - ----- -- ------ -------- -------- -------- - ---- -- -----------------` r---• ---------- -- -- -----F------- - ----------- ---= ------------ - - - - - - ----------------------- ----- -------------------------------------------- raw existing and required addition on reverse side) I hereby certify that 1 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. Horne 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 Work n's Compensati.o aws of California." Signed --------------------------------- -------- ---------• I" f --- - -------- Owner BY �- F.- Title _ (If other than owner) t FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -'-------_-- -- ----- - ------.--. DATE ----��--`- ----7� ----- --------------------------------------------- BUILDING ILDING PERMIT ISSUED ---- -------------------------- - -----------------DATE ADDITION --------- AL COMMENTS --------------------------- ------------------------------------------------- ------------------------------- -------------------------------------------------------------•--------------------- - -------------------------------------------------------------- -------------------------------------------- - -------- --- ------- ------- --- ---- w -- - Final Inspection bya - :�- -------------------------------------------------- ------------------------------Date --- -1I--LI' ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1268 Rev. 5M