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FOR OFFICE USE: APPLICATION FOA SANITATION PERMIT Permit -- ----- --------------------------------- = (Complete in Triplicate) ------- ------------------------------------------------- Date Issued _�-�0-�7-5 _- This Permit Expires 1 Year From Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No 549 and existing Rules and Regulations: 1 JOB ADDRESS/LOCATION --- + CENSUS TRACT - ------------------ Owner's Name -----------------------------------=---------------------Phone ---931_-.-0- o--- ------ --- ---------------- Address --------- --------5-9�``- �----- City _�•Os. - = Contractor's Name .-J �� -------------------------------------- ------License # ------- Phone --Yl93=ss Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court ;[l Motel ❑Other ----------------------------------------- Number of living units4&tl---- Number of bedrooms ----------..Garbage Grinder ------------ Lot Size ----J_V_0k&------------- k Water Supply: Public System and name ------_---- Private [1 -------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe V Fill Material ---_--.----- If yes,type ---------_---------------- tPl'ot 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,) \ fA PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth --------------•------ '`' , I Capacity -------------------- Type ----------- Material---------- ----------- No. Compartments ------ ............... Distance to nearest: Well ------------------------------------Foundation ----------A----------- Prop. Line --------------------- -�$ I 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 -_---------.._--------__ r SEEPAGE PIT [JJ Depth -- ,----- Diameter _ -� j__--- Rock Filled Yes No y Number -_ Cl tJk Water Table Depth -------=4aJ4?,� ----------------Rock Size --�Y - -&x4� P fiDistance to nearest: Well ------1_O_Ft -------------------Foundation ---U�14-------- Prop. Line -.--------.-----.--_- e, REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------} C Septic Tank (Specify Requirements) -----------------------------------------------------------I-------------------:--------- ---------------------- ------------------- --------------------------------------------------'----------------------_--------------------------- Disposal Field (Specify Requirements) ------------ - --------------------------------------- ------------------------------------------------ ------------- -------------------------------------- -------------------------------------- -------------------=----------- --------- ----------------------------------------------------------------------'---------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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, 1 shall not employ any person in such manner as to becomm. subject to Workman's Compensation laws of California." Signed - -� E ----------- - �--- Ow.ner BY -------------------- Sitle ---------- ----------------------------- --------------------------------------------------------- -- i (If other than owner) r FO DEPARTMENT US ONLY APPLICATION ACCEPTED BY -. -- -----------------------------" DATE - ----'------------- - �� BUILDINGPERMIT ISSUED -------------------------------- ------------- ----------------------------- ---------------------------DATE ------------------------------------------- DDITIONALCOMMENTS ---- - ------------------------------------- --------------------------------------------------- - --------------- ------- - -------------------- ------------------------------------------------------------------------------------------ -- F - _ ----------------------------------- -- - - -------------------------------------------------------------------------------------------------------- -- ---------------------- - FinalInspection by: -----------------------------------------------------------------------------------Date J".� �� ------ - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.