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FOR OFF(CE- SE:-` �` APPLICATION FOR SANITATION PERMIT Permit No: --------------- - ------ -------------------------•--------------------- {Complete in Triplicate) --------- ------------ ---------------------- ---------- Date Issued _--'�7-7�/ - 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 County Ordinance No. 549 and existing Rules and Regulations: ',l JOB ADDRESS/LOCATION ---------� ��- ----- --�C----- SQ_V_T __CENSUS TRACT .-S` C -•- ib Owner's Name �...... ' G� --------------- � -------------- -------------------=- t f _ - Phone -------------------------- Cit Address ----- �f- j --------------- ------------------------- - -Tf-�-_--------------------- ----------- Cantractor's Name. � ------------ ------------ -:--- License # �_7� yp__ Phone Installation will serve: Residence [Apartment House❑ Commercial❑Trailer Court T0 Mote I. ` . -.- Number of living units:----�_----- Number7of-Bedrooms -__-___Garbage'Grinder ___________- Lot Size -. Gf fy~" \ __Private F1Water Supply: Public System and nameJ------------------------------------- •- =�` --------: ----------- ---------------------------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑' Sandy-Loam ❑ Clay Loam,13 . - Hardpan ❑-'` Adobe -F-1 Fill Material --------- --- I Yes, type ------------------------ {Phot plan, showing size of lot, location*of sysfem in��r`elation to wells, bu{iFlidings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage ptipermitted,.ifypublic_sewer,is available w,ithirS200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size-----------------------------------------==Liquid Depth -----------------_------- Material---------------- --- ----------------_-------Material--------------= --- No. Compartments ------• --------------- Capacity .r ---------------- Type Distance to `nearest: Well --_ ---__ _ -____Foundafion --------- ----------- Prop. Line ____________________ -------------------- i LEACHING LINE [ ] No. of Lines ------------------------ Length af-each 1ine�e Depth Filter Material length ____________________________ J 'D' Box!------------ Type Filter Material --------------------- P ial ---�1---------------•------•------------- 1 tm � Distance to nearest: Well ----------- ------------ Foundation ------------ ---------- Property Line. ------------------.-.... Depth Diameter __ _- ' d � t 4------- Rock Filled Yes ❑ No i❑ SEEPAGE PIT [ 1 p =------- ---- --------- Number_,- ==-- Water Table'Depth --------------------- ----------- Rock Size ` F Distance to nearest: Well -------+--- -_---------Foundation ------------------ Prop. Line ....------------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------------- - -- ---------------------- Date ___________. ---------`--------- )_ i Septic Tank (Specify Requirements)----------------------------`------------------------------------------------------------------------------------...-------- Disposal Field (Specify Requirements) -------- QD--------IV-----f D-- FLS' i I�------------------------------------------------------ r -------------------------- ' _ ------------------------------------- ------------------------------------- ------ - -� --------- ------------------------------------- -------•----------------------------------------------�i------------------------------------------- _ _ a. {Draw-existing and required add ition-on-reverse-side) I hereby certify that I have prepared this application and that the work will 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: t "1 certify that in the performance 1` the work for whish this permit is issued, I shall not employ any person in such manner as to become subject to or an's Crpensation laws of California. Signed ✓G Owner kBY = Title ---------------------------------------------------------•-------------- (If other than owner) FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY I ------•-------------------------------------------------------------------- DATE ------ -`IT7 --- ------ BUILDING: PERMIT ISSUED.- -----------=----- --- - -•----DATE ADDITIONAL COMMENTS ------------ --------------------- - ------------------ ----------- -- ------------------------------------------ ------------------------ --------------- ---- ---------------------------------------------------------- ------- - ------ ------------- -. - - -- - - - - - __, .- ------------------------------------------------ -------- -------------------------------------Y------- fFinal Inspection b : ------- ---- ----------------------------- -- to _..-------------A-1 SAN JOAQUIN LOCAL HEALTH DISTRICT �J E. H. 9 1-'68Rev. 5M