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" FOR OFFICE USE: APPLICATION FOR SAN, ITATION PERMIT ------- ------------------------------------------------ Y _ Permit No. /I M -(Complete in Triplitate)'_ .._ ----.. l --------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein t described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ��; _ Yom:__- `' CENSUS TRACT I Owner's Name ---------- ----------------------------= Phone '' '-- ` t -`-' MAddress `"'= � =F1 -`-�---------------------------------------- - City ----------------------- ------'r`-------�---= - ❑ Phone 6 Installation will serve: Residence "pa House Commercial Trailer Contractor's Name ___ � -__ ______ ___ _ _ _ _ License # ____ Court ;❑ sa Number of livingunits:---- ______- Number of bedrooms _ Mote ❑ ter ____ � -_ �_=-_Garbage Grinder ---�___ Lot Size ___�_�___�_a__"'_.�`_- `�_____._.. Water Supply: Public System and name ---------------------------------------------------------------------------------------------------•----------Private Character of soil to a depth of 3 feet: Sand b Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam '[:] Hardpan ❑ Adobe rill 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,) G PACKAGE TREATMENT SEPTIC TANK f? [ ] [ ] ' Size__ �__ --------------------- Liquid Depth - o, ' I Capacity ZZ?62_______ Type� r:�_c_y'Material Compartments ___-�.......... .... -- .- Distance to nearest: Well _____ __________________ _ i Prop. ~ - Foundation ----�____----- __ -- ro Line --- ?--------------- Q LEACHING LII IE j No. of Lines __,-3'________________ Length of each, line__--- "-rte-��_._____.__-___ Total Length ____�-' �__._.__ - ( ! 'r' D' Box ---I__.___ Type Filter Material ___ _ Depth Filter Material _____________ Distance to nearest. 1Ne11'_`'` __''' ------- Foundation _-/0_--_________ Property Line --`--------.__ SEEPAGE PIT [ ) Depth -------------------- Diameter ________________ Number ____ ----------------------- Rock Filled Yes 0 No 0 Water Table Depth ------------------------------ -------- --------Rock Size -----------•---- --------------- r 4 Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .. ---. ----------- REPAIRIADDITION(Prev. Sanitation Permit# -------__----------------------------------- Date ---------------------------------- Septic Tank (Specify Requirements) - = -----------------------------------------------------'^---=---•------------------------------•-•--------------------------- ,. Disposal Field (Specify Requirements) ----- ------------------------•-`-;--------------------------------------------------------------- ----------------------•----------- 46- ------------------------------------ ----------- - ----- --- -- ------------------------------------------------ � r .y ________________________________ _ _ �________ _________�_-_�_--•___._-a______________________________-____________.__________________________________. ___ ______ i (Draw a sgng and requir yd addition on reverse side) I hereby certify that I have prepared this{allplica-tio.n and that the work willr be done in accordance with Son 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: = "1 certify that in the performlance of the work for which this permit is issued, I shall not employ any person_ in such manner as to beco a b'ect to Workman's Come t' n la*s of Cd] ornia." Signed _� �_ ,, ' ��Q Owner BY -------------------------------------=-- -------------------------- ------------------------------ Title ----------- (If other than owner) OR .DEPARTMENT USE ONLY APPLICATION ACCEPTED' -- BY `./y� > i � '. DATE _ 'c -° : � - - ------------------- BUILDING PERMIT ISSUED -------------------------------- =k �" .. - ---- ---------- ----- --- ----------------------- _---"=- -=--=DATE - - - - -------------- ADDITIONAL COMMENTS --- ----------------------------------------------------•--•-------------=-------- ------•----------- ------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------- --=-------------------- i a --------- --- °------------------ " Final Inspection by: . a- � _ -- - - ------Date ( SAN JOAQUIN LOCAL HEALTH DISfklCTa ' E H: 1 '68 Rev.'MV1