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FOR,OFFICE USE: Jj xAIPPLICATION FOR SANITATION PERMIT ------------------------------------------------ Permit No: _-------- a (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 ,ounty Ordinance No. 5.49 and existing Rules and Regulations: / Q f C��'} 2,c ---------------------------CENSUS TRACT ----------------_ ------- JOB ADDRESS/LOCAT,I.ON ._- ._ -- Owner's Wme -- --- ----- - ------- - -- - -1`-`— ------------------ --------------- Phone � 7`C-�_------ Addre _ aZ�------ ------------------------------. CitY ----------------------------- --------_-_-•-- Contractor's Name . License # v� y � ___ Phonec., Installation will serve: Residence ❑ Apartment House-E] Commercial Court i❑ Motel ❑ Other , -------------------------------------------- Number of living units------------- Number of bedrooms-___________Garbage Grinder Lot Size __ ___ -__ ________________ ..__. �._ .- Water Supply: Public System and name ------------I---------•---------•----------------------------------------- ----------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 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,) v I Q PACKAGE TREATMENT { ] SEPTIC TANK'{ ] ; Size------------------------------------------------ Liquid Depth:---------- ---,----- Capacity -------------------- Type -----'--------f----- Material---------------------- No. Compartments` I ` .' . Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line ------ ------- '^ 4 LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length .----------j--------`------ ti � 'D' Box ------------ Type Filter Material ____________________Depth Filter Material _________�_______..-_____ _t ---_._ Distance to nearest: Well ----------------------- Foundation ------------------------ Property Line ----------------- ------ SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ N0.0 Water Table Depth ----`-------------------------------------------Rock Size ------------------ ----- Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line ----------..--.-_-.�- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------- ------- /f y Septic Tank (Specify Requirements) ------------------ = y - -----==-------------- Disposal Field (Specify Requirements) v -__ --� -- ---G% ----- -- � --------------------------- ------------------------------------------------------ (Draw existing and required addition on reverse side) 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 beco �su�b*ecfo Wor an4Compensati.o� ws of California." f Signed s/ - �_.. :------:.Owner _ �! __` _ x BY ------`---------------------- 3 - --------------- Title ----------------------- ------------------------------------------------ (If -------------- - (If othe than owner) tf 1 It FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BYE - ✓ ----------- DATE _i2-1:1�7 --a"? `' BUILDING PERMIT ISSUED --------------------- --- 3 ---------------------------- _ DATE ADDITIONAL COMMENTS ----------------------------------------------------__ - e..� "- "�`"` __,- --------------------------------------- ----- --------------- -------------------------------------------------------- ------------------------------- - ------------------------ --- Y ---- . � Final Inspection � ---._ --- SAN J AQUIN LOCAL HEALTH DISTRICT 4 t E. H. 9 1-'68 Rev. 5M