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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 3-4-3 Permit No: ---"----------- --- ----- ----------- -----------------•--------------------- (Complete in Triplicate) e --- ----------- ---------------------------------------------------------- Date Issued - ---- -�----• I This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work he described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: �, . � 1`� --CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION 021k04P--- " Owner's Name _ -- '"�'�_. -.------•-------------------- - ---- ------ - -----Phone ----- ----------------•----------•-- City ------'---------------------------------- �/ - ............... -- --- -- Address ----d r� _7 . ------.License # �� : 7_ Phone Contractor's Name ------- --C.��- - �--�-'J-� --✓-d- -�'k"�'------ Installation will serve: Residence ZApartment House❑ Commercial ❑Trailer Court '❑ Motel ❑Other ------ -------------------------•- Number of living units:------ -- Number of bedrooms -______._--_Garbage Grinder ------------ Lot Size ----____.___ ---- --- -- ------------- --------- ---------Private �~ Water Supply: Public System and name ----------------------------------- - - " " i ' Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .E] Clay Loam O N Hardpan ❑ Adobe,M Fill Material ------------ If Yes,type ---------------------------- p0 (Piot plan, showing size of lot, location of system in relation to wells, lauildings, etc. must be placed on reverse side.) NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) SEPTIC TANK -__ Liquid Depth _____________________.----- PACKAGE TREATMENT [ ] [ I Size-------------------------------------"--- q p ---- p Capacity -------------------- Type -------------------- Material-------------- ---------------------- No. Compartments -----------•---------- i ----------Foundation ---------------------- Prop. Line ------------•-------- Distance to nearest: Well _______________________ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- `D' Box ------------ Type Filter,Material --------------------Depth Filter Material _____________ Distance-to nearest: Well ------------------------ Foundation ------------------------ Property Line --.--------------------- I SEEPAGE PIT [ ] Depth -------------------- Diameter ------_--- ----_- Number ____________________________ Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size-------------------------------- Distance to nearest: Well -------------------------------------- Foundation -------------------- Prop. Line --"----_------.----- REPAIR/ADDITION(Prev. Sanitation ,Permit# ------------------------------------------------------------------------ Date ----------------------------------) - -------------------------------------- -------------I------------------------- --------------------------- Septic Tank )Specify Requirements) __-______._____ ��- is sal Field )Specify Requirements) �" -".... ..... ` --- --- -- -------- --- ----- -- f .� ------------------------------------------ --------- _-_--_---_- _---.---_--___--------_-_. -- C----------`' ` P g _ q (Draw exis n an ire ui d addition on reverse side) I hereby certify that I have prepared,this application and that the work will be done in accordance with San l- r Bai 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 Workman's Compensation laws of California." Signed -----------------------------------6Z�� _ � -- Owner -(:; °�Title --------------------------------------- ---------- (if other than owner) FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY .- -- -- - - -- - DATE s� --- --------------- APPLICATION ---------- -- --DAT ---- --- --------- -------•----------•--- BU1LDiNG PERMIT ISSUED _-- -- --------------------- ---------- ------- -------------------------------------------- ADDITIONAL COMMENTS ---------- ------------------------------------------------------------------=--------------------------- ----------------------- ------------------------------------------------------------------------------------- ! „�- -------------------- ---- - ------- --------------------- --------Date - -- Final Inspection by.-? -- ,�-�--� __� ._- ------ --------- ------------�----- -- �� SAN JOAQUIN LOCAL HEALTH DISTRICT Arm+ F u o 1-'68 Rev. 5M