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c FOR OFFICE USE: rt APPLICATION FOR—SANITATION PERMIT ,f I -------------------------------------------------------- -" Permit No. �7r-�s� {Complete in Triplicate] _------------------------------ This Permit Expires 1 Year From Date Issued Date Issued --3 - 4 Application is hereby made to the San Joaquin Local3 Health District for a permit to'-construct and install the work herein described. This application is made.in compliance with County Ordinance No.549'arid existing Rules and Regulations: JOB ADDRESSJLOCATION -- - --- .1 -----._CENSUS TRACT --- ------ Owner's Name ------------- - - - - - - `;'� ,.-- - - - -��1Q_l�l----------------------•�---�-----� x ly �.--------- ->� ._ ------------------------- Address ----------------- - Phone ---= '----�-: Address } -----�-�--�..fo:-- --------- • �Uu�-�---=- 4 city E e , Contractor's Name -------------------- ----- -----:License-#- -------- Phone ------------------------------ Installation ---------------- ------Installation will serve: gip. Residence �rtment House❑ Commercial ❑Trailer,Court-;❑ Motel ❑Other ------------ =.! ~- ----- ----------- Number of living units:--- 1----- Number of bedrooms -__ ! Garbage Grinder ----°-'_- Lot Size ______-_--------------------------- ------ / : Water Supply: Public System and name------------ � l - = --------------Private ❑ \>r Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam'E] t } ! Hardpan ❑ Adobe ❑ Fill Material --- ------ If yes`type ---------------------------- f (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•p rmitled if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Sizer------------------------------ ------------ Liquid Depth -----_-----_---------_- __ 14 Capacity Type Material__'____---------t: --'No Compartments ................... .. pct y --------------- -- yP -- - .� Distance, to nearest: Well --------- -------------------------Foundation --. ---- ----------- Prop. Line ---_---- LEACHING LINE ( ] No. df Lines --------- -------------- Len th of each line---- -------------- Total Length _-_--_- a 'D' Box ---_-------- Type Filter Mate ial --------------------Depth Filter Mat rial -------------------------------------------- Distance --_-----_--_-_----_._----___-__-----.----- Distance to nearest: Well ----------- ---------- Foundation --------------------- Property Line. ---------.___--__-_.__ SEEPAGE PIT [ ] Depth _ _________________ Diameter __ ------------- Number ------------------------ --- Rock Filled Yes ❑ No i❑ Water Table Depth _.._-____-_Rock Size ---------_ ----------------- - ----------------Distance to nearest: Well ------------- ------_� _ __Foundation ------- ---------- Prop. Line -------- ------------- �. s REPAIRJADDITION(Prev. Sanitation Permit# ----------------------------------------------Date :------------------------_-------_} Septic Tank (Specify Requirements) I ----------------------------._----- --- ------------ ---------- Disposal Field (Specify Requirements] -----_- W =t='---�'� - --- ---_---_ _-_ -------------------------------------------------- -------- ---------------------------------------------------------- ---------------------- I i (Draw existing and required dddition 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 p rfbrmance of the work for which this permit is issued, I shall not employ any person in such manner ' as to become ubject to Zm ,'s C ensati, n laws of California." I Signed --------- Owner r By ----- ------------------------------------------------------------------------------------- ------- Title --------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- -- ----------------------------------------------- DATE ---- ------ ------------ BUILDING PERMIT ISSUED --------- ---------------------------------- ---------------------------------------DATE-_^---------------------------------------- ADDITIONAL ---f-----------ADDITIONAL COMMENTS ---------I------- ------------------- ----- -------------------- - -- --- ---- - --- -_-------------------------------------- --- -------------------- -------- -- ---- ----------- ------ --------------------- ---------- --------------------- -- ------------------------------------------------------------- --------------- ----------- -- - - - --==---- . ------------------- --- - -- --- - Final Inspection - --------- -- .C�--- -- ---------------------------------Date ----- -------- - I SAN JOAQUIN LOCAL HEALTH DISTRICT I. - t E. H. 9� 1-'68 Rev. 5M.