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FOR OFFICE °USE: APPLICATION FOR SANITATION PERMIT --------------`-----------=-------,----- ---- ---------. Permit No. ._ellf-_71T �� __ ,�- (Complete in Triplicate) � This Permit Expires 1 Year From Date Issued Date Issued _J :_ Application is hereby made to the San Joaquin Local Health District for pp y q 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: t - ,`�-U-�2d JOB ADDRESS/LOCATIO ►t---`'�� ------------- - - �__CENSUS TRACT --•----------- ----------- -- Owner's Name - = ------�--�-4-=�'----------------------•- ------------------------ -- - ------------------Phone --------------------------- -------- ,i Address -- ---- ._ _ � --•--. :- city Contractor's Name -- -- -- -------------=------- License # ------------------------ Phone ------------------------------ Installation --- -------------------- Installation will serve: Residence X Apartment House❑ Commercial :❑Trailer,Court ,❑ Motel ❑Other ---------------------__------------------ Number •_ ------------------- Number of living units:----- Number of bedrooms ---- '_-..Garba_ge Grinder___ Lot Size-Q' 4 ------------------------- Water _ _______________Water Supply: Public System;and name --------------------------------------------------------------------------------------•-----•--•----•---------- Private i Character of soil to a depth of 3 feet: Sand b Silt 0 Clay ❑ Peat❑ 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 Iseptic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK] Size ____ V___3C---- ------------------ q p I Capacity, 5.O--O------- Type 'QTR---I -- k PIS Y I -- Material.- �----_-__-- No. Compartments -�'"'---•-.-•...:-•-- Distance to nearest: Well -_-__Z_A`--------------------Foundation _J_0---------------- Prop. Line __ �_. .._._..._.. LEACHING LINE [ ] No. i�of Lines ---.I__________________ Length of each line._�710 __-'__.k'_$Gfotal Length ...... `D' Box _�--_ Type Filter Material AA------------Depth Filter Material _____ rf---------------------_---- Distance ___DistInce to nearest: Well ---------- ------ Foundation ------------------------ Property Line ---------__ ----- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -------------------- -------- Rock FilledYes E] No )❑ ) Water Table Depth ------------------------------------------------Rock Size ---------------------- ------ -- _ DistaII nce to nearest: Well -..____________________________________Foundation -------------------- Prop. Line .......... REPAIR/ADDITION(Prev. Sanitation Permit# _______________.___._______-- ___--------._ Date ________.-______._______._________j I Septic Tank (Specify Requirements) ----------------------- --- - - ---------------------- ----------------_•---------------------------- Disposal Field (Specify Requirements) ____________ ________________'______ -------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------- -- --------------------------------------------------- ------ n U - . 0. (Draw existing and required addition on reverse side) -- - --,�.- -a 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 ficen- 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 f California." i . Signed� , 2 .�. .: --�� --- _------ ------------- Owner BY --------------------------------------' ------ ------------------ -r ---------------------- --------------------- -- Title --------- ---------------- -----------------------------------------=-- - (If other than Owner) I[ ,dP FOR .DEPARTMENT USE ONLY ,r. APPLICATION ACCEPTED BY .: -- - - --------------------------------------------------------------- DATE ' `�------•------------------- BUILDING PERMIT ISSUED --- -------------------------------------- DAT ADDITL COMMENTS �� - rJ A 2_�1 - . _- "� ------ a ------------------ -- --�-----____---------------------- ---------- ,__ I . - --------- -------- ---- ---�I, ________________ ____________________-___ ---____.________.______-______ ____._____________-______________-_-__-__._-__.___________._.__________.__________-:______________-_-_____.-_____ FinalInspection by- ---------------f------------- -- -------- - ----------------.Date -------------------------------- -- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT . E. H. 9 1-'b8 Rev. 5M