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1=oR OFFICE usE: APPLICATION FOR SANITATION PERMIT _ ------ ----------------------------------- Permit No. a 6 (Complete in Triplicate) --------------------- ------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued --------- ---- t -------------------------------=-- - j /�� 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 with County Ordinance No. 549 and existing Rules and Regulations. } JOB ADDRESS/LOCATION ---- ---- ---- CENSUS TRACT -------------------------- Owner's Name -- " -------------------------- ------------ -------- = Phone --- Address 1.0214------- --------•--. City -- 7e; ---------•---..._- Contractor's Name ._ _�!____ -.___ License # -- - -- Phone _ ,.� =_. _all I Installation will serve: Residence �4ment House❑ Commercial❑Trailer Court Motel ❑Other ------ ------------------------------------- t • Number of living units------------- Number of bedrooms --4C------Garbage Grinder ------------ Lot Size --___-----.----------_---_--------_-.--_. iWater Supply: Public System and+name --------------------=--=-----------------="-- --Y" . . _ _ -Private gt� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑...Clay Loam Hardpan ❑ Adobe '❑ Fill Material ------------ If yes, type -------------------- -- i (Plot plan, showing size of lot, .location of system in relation to wells, buildings etc. must be .placed ori reverse side.) , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ 2 SEPTIC TANK [ ] Size------------------------- q p F Capacity A6 'f- -.,-- Type _� _ Material---------------------- No. Compartments --------.---------.--- r t 0 " i Distance to nearest: Well ---10�-------------------------Foundation J40.---_-----_---_ Prop. Line -----_---- --:-------- i f LEACHING LINE No. of Lines ----_ Length of each line--7ef------__--__-___ Total Length .---------_ [ ] 2. p i. 'D' Box --�L----- Type Filter Material --- _Depth Filter Material _ --- -------_______________________ Distance to nearest: Well ------/0---------- Foundation ------------------------ Property Line. ---------------.--._.--- ] SEEPAGE PIT { ] Depth -------------------- Diameter ------------ --- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table' Depth ----------------------------------------- ----Rock Size ----------------------•----; Distance to nearest: Well --------------------1"------------•-------Foundation -------------.--.--- Prop. Line --------------_. f REPAIR/ADDITION(Prey. Sanitation Permit* --------------------------'------------------ Date ----------------------------------11 A 'Septic Tank (Specify Requirements) ------------------------ ------••-----------------------------•--------------------------- Disposal --------------------------Dis osal Field JSpecify Requirements) -------- -------------------------------------------------------------------------------------- ------------- t- n -------- t-------------------------------- (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin 5 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 ----------------------------------------------------------- -------------------------------- Title --------------------------- -- - ------ --------------------------------- - - - (If other than owner) Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- ----------------------------------------------------------------------- DATE ...-� T ------------------ ------------------- ------------- BUILDING PERMIT ISSUED --------- '-------- DATE --- ADDITIONAL COMMENTS ---- !frit'`c` � "� ._ -' ` '`� --------------------------------------------------------- ------------ -- -----------------------------------------------I-------------------------------------------------------- ------------------------------------------------------------- --------------------------------------------------------------------------------------- -------------- --------------------------- ---- - -- -- - --------------------------------- Final Inspection b --------------- Date l ' _ P Y: ------------------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'S8 Rev. 5M