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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. t. ------ --------------------------------------- (Complete in Triplicate) -------- --------- --------- --------- -------- - -- Date Issued - This Permit Expires 1 Year From 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 Ordinance No. 549 and existing Rules and Regulations: CENSUS TRACT '-S--cam- --- _ JOB ADDRESS/LOCATION .__ '--------------- ------- Owner's Name 1 ��k _h_v- `i. ---------- Phone --I Address 2- s� r 1 ._(Z/ --tom i'_-< ------ city �i2 f/"� -------.License # ` _ / Phone ��`�� - Contractor's Name _ ------ _�- _—•_ ._ - ---- - ------------------- Installation will serve: Residence ® Apartment House❑ Commercial :❑Trailer Court ',❑ Motel ❑ Other ---------------------- -------------------- Number of living units:-_-I ------ Number of bedrooms __3----- Grinder ----- ------ Lot Size Private r-1Water Supply: Public System an name --------------------------------------------------------------------------------------------------- Character of soil to a depth of 3 feet...,._Sand'� Silt C] Gay F1 Peat El Sandy Lodm ❑ Clay Loarri 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 -------------------- Compartments ------------------- V No. Com artments Capacity -------------------- Type ---------------- - Material---------- ------ p { Distance to nearest: Well ----------------- ---=--------- ---Fou dation ---------------------- Prop. Line ---------- ------------ ----- Total Length ----------- ----------- No. of Lines ------------------------ Length of each line__ ____ - - u LEACHING LINE [ ] - i e th Filter Material --___------------------------ -- 'D' Box _________-- Type Filter. Materi I ________________ __ p - - -------___ Foun tion Property Line_ ------------------------ F pistance to nearest: Well __-_____ --- --------- --------- SEEPAGE PIT [ ] p Diameter - _____________ Rock Filled Yes ❑ No .1[] Depth --------------- N ber Water Table Depth -------------- -------------------- -- ---Rock Size Distance to nearest: Well ____ ____ _________________ _____ .Foundation Prop. Line . REPAIR/ADDITION(Prev. Sanitation Permit ------.-------------------------------------- Date -------------------•--------------) Septic Tank {Specify Requiremenfis) --- ------/---------------------------------- ---------------------=-------------------- .. C= am -----Al Disposal Field (Specify Requirement ) _-- --- --- --G _--- f' L ' ------------ ------ -- Y s -- _-_=-- - —.._ (Draw existing and required addition on reverse si e l 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 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 rkman's Compensation laws of California." iSigned ------------------------- �---- - ------------------------------- Owner By --- Title ---------- -------- ----- -- -- ------ -- ------------------------ - - (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- ----��----`- -------- ---------- ------- - -------- DATE --- -�-----_; P-25----------- BUILDING PERMIT ISSUED ------------------------------------------------------------------- ---- -------------- ------ -------DATE --------- ----------------- --�---�----� , ADDITIONAL COMMENTS ---- - ---- - ---------------------- --------- ---------- # ------- --- --- - -- t ^_ r - ------ --- __.Dae ------ - --�--------- 4 Final Inspec --- -----I Ul1V LOCAL i { SAN JOAQ HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M