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FOR OFFICE USE: 70 // APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ----------------------------- --------------------------- This Permit)Expires 1 Year From pate Issued 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 nth Cou Ordinance No 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . _.__.0-------- CENSUS TRACT -------------- Owner's Name ------------------- - -- -- - -------- Phone Pho * - -- �� Address - - _�- --------------- -- ----------- City 1 Contractor's Name ------------ ----------- .-- -- ----- - ---- ------ -Vi t .--:----.License # -51--------- Phone Installation will serve: Residence Apartment House,❑ CommercialjE3Traller Court i❑ ,JMotel ❑Other -------- ---------------- Number of living units:____. __--_ Number,ofE;edroonis� �__-Gar a e Gr'n er .._-____. _ Lot Size _ ---------------------------------------- Number ____________ _ _ _____ --�� raj, � --------•---••--- y ----:--O ------!W----_ Private ❑ Water Supply.. Publics stem and name~_;t.-___ f Character of soil to a depth of 3 feet: Sand'[] Sift❑ 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 septic tank/or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size------------------------------------------------ Liquid Depth ---- --------------------- Capacity .......- -------- --- Type ----------- �+ �� --_-__-- Material---------------------- No. Compartments ______.___------____-- 111 Distance to nearest: Well ___________________ ________________Foundation ---------------------- Prop. Line __________....__,._____ LEACHING LINE [ ] N o. ,o)f�Tinesj�_1:---------------- Length of each line---_-----_------------------ Total Length -_-------------------------- sr Ir z . � D Box .___._-._.— ype Filter Material ____________________Depth f=ilter Material --------------------.---------------........ Distance to n ebrest'Well ------------------------ foundation ------------------------ Property Line --------_---------.--•-- SEEPAGE PIT [ j Depth ------------ ---- Diameter ---------------- Number ---------------------------- Stock filled Yes F] No CWater Table Depib ------------------------------ -------Rock Size -------------------------------- Distance to nearest�Weli tk- �� -----Foundation -------------------- Prop. Line ...................... ; REPAIR/ADDITION(Prev. Sanitation Permit# --------- --------------- - Date ----------- •--_-_-- ------- Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) -------------� _-- �- /aj ------------ �i -------------------------------------------------------------------------- ------------------------ ------------------- -- ------------- -------- -------------------------------------------I------------------------------------------------------------------------------------- (Draw existing and required addition' on reverse side) I hereby certify that I have preparecllthis application and that the work will be done in accordance with San Joaquin i County Ordinances, State Laws, and Rules and Regulations of the SonflJoaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the'work for-wkich-this permit1s`i Isued, I shall not employ any perso in such manner as to become subject to Workman s Compensation laws of California." j Signed --------- --------------------- ----- -------- ----- ----- Owner By - ------ - ------ =� - ------ Title ----- ------------ --- -------------- If other th ner) `';.OR RTMENTkUSE ONLY APPLICATION ACCEPTED B DATE f-?. -7d --------------------•------- BUILDING PERMIT ISSUED --------------------------- ---------------------------------------------------- -DATE --------------- --- -------------- ADDITIONAL COMMENTS ----------------- ----------------------------------------------- - -----------------------•---------------------------- -------------------------------- - --- -------------------------- ---------------------------------------------- ------�-'--�- - - wy� -------------------------------- ------------------------------------- --------- FinalIns ection y __-•- --- --------------------- ------------------------------------------Date ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M