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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------- (Complete in Triplicate) Permit No. 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO N :j� K- - ----CENSUS TRACT --------------•----------- Owner's Name --------------- ----------------------Phone ------------------------------------ Owner's Name »d ------- .�Pe. Cit c�- ,.z ---------------------------- Contractor's Name --- CL?J7r1�.t z_ -_----.License #/� ':- _ : Phone __-____________________ Installation vrill serve: Residence Apartment House❑ Commercial :❑Trailer-Court- E] Motel ❑ Other ------------------------- -- ... Number of living units:_.___I Number of bedrooms ___3____Garbage Grinder ------------ Lot Size ____ _ -- '__-._______- Water Supply: Public System and name -----------------------------------------------------------------------------------------------z,--------------Private Cr Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [ Clay Loam:❑ Hardpan ❑ x Adobe'❑ Fill Material :________:__ If yes,type ____________________________ r (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 1 [ ] [ l �'`� Size----Y------------------------------------------- Liquid Depth ------------------------ Capacity ------------------ --•-Capacity ------------------- Type--------------------- Material----------------------- No. Compartments -----------_---- Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line ----------- LEACHING ---------LEACHING LINE [ ] No. of Lines ___ _________________ Length of each line-__----_-_--------- g - Total Length ----------------------- 'D' - --•----•---•-------'D' Box ------------ Type Filter Material ----------I--------- Depth Filter Material ------------------------------------------.- � r Distance to nearest: Well ------------------------ ------------------------ Property Line --------------------- SEEPAGE _________________-:SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---_------------------------ Rock Filled Yes '❑ No .0 Wafter Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------F6undation ---------------•---- Prop. Line _..................... t REPAIR/ADDITION(Prev. Sanitation Permit # ----- ---------------------- Date -__-____________________________-_} Septic Tank (Specify Requirements) ---------------{:- ------ - - D osaI Field (Specify Requirements) --------- ---- -sti„��- _ _ - -- ' ' d- / - ----- r �-z: -.-.---------------�---- J 00 ---- ------ ---- _ � -, • 4 ----------------------------------------------------------------------------------- _ -------.w.�.-------------------------------_ -------------------------------------------------__-------._ (Draw existing and required addition on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensatio ws of California." Signed ---------------- - -- - -- -- --- ---- -- ----- ------- -------------- Owner c -- Title (If other than owner) FOR DEPARTMENT USE ONLY cc APPLICATION ACCEPTED BY -- -- - ----- -- -- - - - - ------------------------------------------------------------- DATE 4-- , 7 d----------------- BUILDINGPERMIT ISSUED ---- ----------------------------------------------------------------------------------------------------DATE -------------------------------- ---------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------- --- ------ -------------------------------------- - - -- ---------- -------- - --------------------------------------------------------------------- ---------- - - -- -- Final Inspection bY ---------------------------------------------Date --------------------------------`- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M