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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT Permit Na.t._ '� ._.....----•....................................... {Complete in Triplicate) .............. - � 97 _.... . -- Date Issued :......... ......... _......-•• _......._........ This Permit Expires 1 Year From Date-issued •i 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: ... .......... ... . ... ................CENSl15 TRACT .. JOB ADDRESS/LOCATION .....�SS..I•.............. Owner's Name' - . .- ................... ......... .................................,......Phone ..,.,.... ,....................... Address . . ...... .1 .. ._. ..................... ...._..City .... ...... ...... ... Contractor's Name -z-�1�Z —' . # .��? .......... one .............................. y 7. installation will serve: Residence[ 4cirtment House Commercial OTroller Court Q Motel Q Other .......................... ..... Number of bedrooms Garbage Grinder ............ Lot Size .........- ..••••••••• ................... Number of living units:..... - -•--•••• Water Supply::Public System and name ... . Private Character of soil to a depth of 3 feet: Sand Q Silt❑ s Clay 1:1 Peat❑ Sandy loon Q Clay Loam [3-`_ Hardpan[] Adobe 0 Fill Material If yes,type ............... ............ {Plot plan, showing sire of lot, location of system in relation to wells, buildings, etc. must be placed on reverse sid&T, - NEW INSTALLATION: {No septic tank or seepage pit permitted If public sewer.is available within 200 feet,) .. Liquid. Depth 4r PACKAGE TREATMENT ( ] SEPTIC TANK ] �,. Size.-_.................... ..._......................, Capacity Material............... . No. Compartments .....................C _.....---•-----••- Type ••--.......:.... L Distance.to nearest: Well Foundation ...................... Prop. Line ......... ........----• LEACHING LINE [ } No. of Lines ------------------------- Length of each line............................ Total Length ...._... ................... 'D' Box Type Filter Material ......De.pth Filter Materia .............••.............. �- er Line Distance to nearest: Well ....................... Foundation .... ........... Property SEEPAGE PIT "[ l Depth -........ Diameter ---"-.........._ Number ---..--•-..-.._..---- Rock Filled Yes Q No ...- : WaterTable Depth-------- ------------- -------...................Rock Size ..... .......................... � ... ...... • :Foundation --- Prop. Line ...................... Distance to nearest: Well ............. EI REPAIR/ADDITION JPrev. Sanitation Permit#._.-...--.-- ................-......... Date ..-.•-••---•---.........• 1 Septic Tank (Specify Re uirements# ........................ a Disposal Field (Specify Requt ents# -------............--------••-......_:_...----............._ ................................................._._.__... -:--- �- ............. . ao (Draw 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 Lecat Health.District. Homo owner or liven• sed agents signature certifies the following: erson in such manner "1 certify that in the performance of the work for which this permit is issued, I.shall not employ any p as to become subject to Workman's Compensation laws of California." Signed --•--------•-•---•---- -• -- -••---- ----•--••- -----------------• Owner _ 4 BY ------- _..--_...__. Title - .................. ........ (if other than owner). FOR DEPARTMENT USE ONLY .-_ APPLICATION ACCEPTED BY ------------ '` — ----------------------------- . :. .....DATE,;.;:, ..�..� .. - _ ....DATE ..... -- •---•-•---..__...--••-- ....... BUILDINGPERMIT ISSUED ............... -----•-- --------------•-----_-._. ----.._..--------- ................ -. ADDITIONALCOMMENTS ------------ --•--- -------------------- --------7—---- -------------------- ---- ............. ..... .;... - -------------•----- --•------ -------••--------•--------- - _ Date .............. Final Inspection b =-----..---••----• EH 13 211 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M a