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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 _/�_6.77 9 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 an d existing Rules and Regulations: JOB ADDRESS/LOCATION .- _.---- -- --- -_,-- ----------- lG�--- --CENSUS TRACT Owner's Name ---- --- -- --- --- - ---- --------- -- one -- 6 ----- - Q Address ------------------- -----_ _ Ci ---- -------- ----- --•--- Contractor's Name --- --------------- -- �_ _,9 � _• --_---------.License # phone Installation will serve Residence, Apartment use:❑ Commercial:❑Trailer Court {] Mote! [:1 Other '= Number of living units:-----I---- Number of bedrooms -----Garbage Grinder -.___�„Lof"Size -------Cg Water Supply. Public System and name ------------------ „,,�� 11 Private ❑ Character of soilhto'a o 3 feet: Sand tle th ' Silt Cl P ❑ ❑ 1 l y E] Peat i�f` Sandy loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ------------ If ,esi Y tYPet --- -------------- (Plot plan, showing size of lotY ioeation of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: r- t r �(No, �ep�i- ta� -or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT � SEPTIC TANK t l Size------------ ---------------------- ------ Liquid Depth - •-------------------- Capacity ------------------ Type -- -_--------------- Material-------------- - --- N'o. Compartments t Distance to nearest: Well --:--_.Foundation ------- ------------- Prop. Line ----------.----------_- `r LEACHING LINE [ ): No. of Lines ---------------------.-- -!ength of each line.--.__-_-_________�-.___.-_ Total Len th `N 9 ----------- ---------------- \,� 'D' Box ------------ Type Filter Material -------------------Depth Filter Material --_---_ _ V} Distance to nearest.-Wei1 -�.__--_____-_�_ �aundation -_____----___ I l .w� ---- Property Line � ---- -------------- SEEPAGE PIT --••- [ ] Depth -------------------- Diameter ---------------- Number ---------------------------. Rock Filled Yes ❑ No ❑ t Water Table 1 Depth ----------- --- -----------------------=--------Rock Size ---- ---------- Distance to nearest. Well -N------------------------------------ Foundation ------------------- Prop. Line -------------,--•-__-- i REPAIR/ADDITION(Prev. Sanitation Permit# ---------_ ---I----------------------------- Date ----------- -- -------------------- Septic Tank (Specify Requirements) ------------------ -- _ Disposal Field pec'ly - --.--�-�---- ---- _ --r-------- -- - -- - ------- ---------------------- --------------- --------- . sdrrequired addition on reverse side): ihereby 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 affRegulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: I "F certify that in the performance of tl'e work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation taws of California.” Signed --- ------ --------- Owner -------------= By -------- -- -- - -- - - --------------------- Title ---- (if other t owner) (FOR`DEPARTMENTLISE ONLY APPLICATION ACCEPTED BY ___ _ __ � ,�.,-------------------------------------------- =---- - ----- --- DATE --- -�•_��`_��------ ---- BUILDING PERMIT ISSUED ------------------------- ------- -DATE -----------------=-_!------ -------------------------- ITIONAL COMMENTS ---____---- ----------- --------------------------- - ---------- --------- ------------------------ --- ------------------------------------- ----- ------------------------------------------------------------- - ------------ - ------------------------------------------ n --------------------------- ---- - ------------------------ - ---------------------- - - --------- - -- --Final Inspection bY -- - ----------------- - - ------•----- -------------- -----Date// � -- - SAN -------- JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M•