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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----------------- -------------------------- (Complete in Triplicate) - ---- ------ - -------------------------- - Date This Permit Expires 1 Year From Dale Issued Application is hereby made to the Soni Joaquin Local Health District for a permit to construct and install the 'work herein described. This application is made to compliance with County Ordinance Nq n existing Rules 7 nd Regulations: r<C�gr+VC � - 3J JOB ADDRESS/LOCATION_ SUS TRACT -------------------•-•---- ' Owner's Name -------- 1�- - one 4e 79-1-F-1 - _----- ' Address ---- ----------------------- ------------- ----------�� ---�� -.�----------- -- ----------- cry Contractor's Name ----�-- ----- ----- ----- - a' - License # op Phone - 1..- ` E Installation will serve: Residence XApartment House❑ Commercial :❑Trailer Court ;❑ f f Motel ❑Other -------------------------------- --------- Number of living units:---- Number of bedrooms _--.7-----.Garbage Grinder --.,--.- Lot Size `�n-_` _ . �_-•--- Water Supply: Public System and name �------------------- t.c M Private f Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [3 Hardpan ❑ Adobe Fill Material ------------ If yes,type ---------------------------- (Plot -----._-_---- ---___(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 ['J Size--- --------- Liquid Depth ----a�^--------------,-- CapacitylgW--44 Type P1c'A4X- Material--{'-�s- No. Compartments -. --------------- i Distance to nearest: Well ----�' _`------- --------------Foundation ---/0---_------ Prop. Line LEACHING LINE Qd No. of Lines ----�-------------- Length of each line------F�-r-.------- Total Length -/. -- ------------ 'D' Box ---tl----- Type Filter Material ---/ ---Depth Filter Material _-- --------------------- Distance to nearest: Well -_ S^ ��-, " ---__ Foundation _.__ --- Property Line -- -:---- i SEEPAGE PIT J"' Depth __ _ _'----_- Diameter ---------------- Number--------------- Rock Filled Yes No i❑ Water Table Depth -------1� -------------------=----------Rock Size " --------- ------------ Distance to nearest: Well --- - -----------------------•.Foundation ---e-111- ----- Prop. Linem�---._.....• -- t - , REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_----.-__-_--_---- Septic Tank (Specify Requirements) ---------------- --------------------------------------•----------------------------,------- --------------------- ` Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- --------------------------------- - --- -----------------------------•--------I---------------------------- I ------^Ri--- I__ __ that I have prepared this application and that d e -------------------------------- ------- - --------- ----- ----------------------- ----- (Draw existing and required addition on reverse side) , I hereby certify p p pp a work will be done in accordance with 5a 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 foe 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 i Title .------... -ti ✓,* � BY -' ----- ------- (If other than owner) ---- `"-` t. o FOR DEPARTMENT USE ONLY APPLICATION)ACCEPTED BY,.,. ---- - ---- ------- -------------------------------------------------- ---- -------------------...DATE ' � '"`r��. BUILDING PERMIT ISSUED ------- ------------------------------------------- - ------------ -------DATE ------------------------------------------ ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------- ------------------------------------------------- --------- ----�_- '' `--�---- --------------------------------------------------- ------------------------- ------------------- ---------------------------------- --------------------- Final Inspection by: _._ - Date __ �_rt�- =- -----------=------- -------------------------------------------------------------------------------------- ---- --- --- -- --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. W 9 1-'68 Rev. 5M