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FOR OFFICE USE: _- -� APPliCATiON FOR SANITATION PERMIT p p� { ------ ------------------------------------------------ "" (Complete in Triplicate) Permit No. 4p ---------------------------------------------------------- this Permit Expires ] Year From Date Issued Date Issued /5�-C7'�F 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 ADDRESS/LO TION _-�.(o ----------- ------------------- --- ------ --------- ----- - -- --•------ --- --- CENSUS TRACT --- Owner's Name -------------------------------------- Phone - _s f Address _ 5 - -�-�, - ------------------------. City -: --------- 1- ------------ C --- - -------•-------- - ----�--- ------------ ---� ------.LicensO# --- - -------------- Phone ----------------------------- Installation will serve: Residence A artment House Commercial Trailer Court Motel ❑ Other t Number of living units:...!_------- Number of b rooms J_______Garbage Grinder _ -__ Lot Size ------------------------------------------ Water --5�_ X I ---------------------- r Water Supply: Public System and name _____________ ' -----. ---- --------------------- ----------------Private ❑ - - Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Gay Loam.'❑ Hardpan Adobe Fill Material ____________ If es, p ❑ ❑ Y 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'f ] Size--------------------------------- -------------- Liquid Depth -------------------------- Capacity -------------------- Type - ---------------- Material----------- ---------- -No.- Compartments ------ ------ a 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- '^ " r -----•--------------------- Distance to nearest: Well ------------------------ Foundations ------------------------ Property Line ------------.----------_ SEEPAGE PIT [ ) Depth -------------- ----- Diameter ---------------- Numbw ---_.----------- ----------- Rock' Filled Yes ❑ No I❑ � Wafer Table-Depth ...,... - --------------------------------hack Size --- -------------------- Distance to nearest: Well ----------------------------------------Foundation ------------ ------ Prop. line ---------------------• REPAIR/ADDITION(Prev. Sanitation Permit# 1_71_()__L--k_ __- Date _ _'-_ _'-� -------------- -- Septic Tank (Specify'Requirements) ---------------------------- Disposal Field Specify Requirements) -_�_ -s _.___ _____-,r�- _ ' --------- - r ----------------------- - - --- --- - --- ------------------ ----- -- --------- ----- --------------- 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 A 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 whid+ihis permit is issued, I shatl not employ any persen in such manner as to become bl"t to Work m 's Competi ati`on s of Cal'ifomia." Signed - ----- __ _ 71ite er l t }. BY ------------------- ----------------------- ----------------- --------------- (ifother than owner) FOR DEPART MI NT I ISE ONLY BUILDING PERMIT ISSUED .- — ==='=_`` _ = _ =------- ------------------------------------------------ ----------------- ------------ APPLICATION ACCEPTED BY _____-. -__ DATE ------- ----- ----------- -- ----- ADDITIONAL COMMENTS ---- ------------------------------- ------------------------------------------ -- - ----- ------- ----------------- ----------------------------------------------------------------------------- ------ - -- - --- - --------- }} Final Inspection by: ---- --_-�. -------.Date --- C-- j ----"~-. �`- SA JOAQUIN LOCAL HEALTH DISTRICT E. H- 9 1-'6B Rev. 5M. r